Provider Demographics
NPI:1063819720
Name:BLUE RIDGE MEDICAL MANAGEMENT
Entity Type:Organization
Organization Name:BLUE RIDGE MEDICAL MANAGEMENT
Other - Org Name:MSMG VAS SURG NOR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:CARL
Authorized Official - Middle Name:STEPHEN
Authorized Official - Last Name:KILGORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-915-5116
Mailing Address - Street 1:98 15TH ST NW
Mailing Address - Street 2:SUITE 201B
Mailing Address - City:NORTON
Mailing Address - State:VA
Mailing Address - Zip Code:24273-1600
Mailing Address - Country:US
Mailing Address - Phone:276-439-1490
Mailing Address - Fax:276-439-1495
Practice Address - Street 1:98 15TH ST NW
Practice Address - Street 2:SUITE 201B
Practice Address - City:NORTON
Practice Address - State:VA
Practice Address - Zip Code:24273-1600
Practice Address - Country:US
Practice Address - Phone:276-439-1490
Practice Address - Fax:276-439-1495
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-24
Last Update Date:2017-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01012545932086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VADF7910OtherRAILROAD MEDICARE
VA622968500OtherDEPARTMENT OF LABOR
VADF7910OtherRAILROAD MEDICARE