Provider Demographics
NPI:1003152307
Name:BLUE RIDGE MEDICAL MANAGEMENT CORPORATION
Entity Type:Organization
Organization Name:BLUE RIDGE MEDICAL MANAGEMENT CORPORATION
Other - Org Name:BALLAD HEALTH MEDICAL ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT / CEO
Authorized Official - Prefix:
Authorized Official - First Name:CARL
Authorized Official - Middle Name:STEVEN
Authorized Official - Last Name:KILGORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-302-3051
Mailing Address - Street 1:410 N STATE OF FRANKLIN RD
Mailing Address - Street 2:SUITE 120
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-6971
Mailing Address - Country:US
Mailing Address - Phone:423-431-2350
Mailing Address - Fax:423-431-2372
Practice Address - Street 1:410 N STATE OF FRANKLIN RD
Practice Address - Street 2:SUITE 120
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-6971
Practice Address - Country:US
Practice Address - Phone:423-431-2350
Practice Address - Fax:423-431-2372
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-14
Last Update Date:2019-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN020487821OtherDEPARTMENT OF LABOR/BLACK LUNG & ENERGY
TN020487821OtherDEPARTMENT OF LABOR/FECA
VA1003152370Medicaid
TNQ002409Medicaid
TN3709285Medicare PIN