Provider Demographics
NPI:1073555934
Name:BLUE RIDGE MEDICAL MANAGEMENT CORPORATION
Entity Type:Organization
Organization Name:BLUE RIDGE MEDICAL MANAGEMENT CORPORATION
Other - Org Name:MSMG NEUROSURG JC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
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:423-915-5116
Mailing Address - Street 1:408 N STATE OF FRANKLIN RD
Mailing Address - Street 2:SUITE 42
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-6089
Mailing Address - Country:US
Mailing Address - Phone:423-431-2350
Mailing Address - Fax:423-431-2372
Practice Address - Street 1:408 N STATE OF FRANKLIN RD
Practice Address - Street 2:SUITE 42
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-6089
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:2006-06-12
Last Update Date:2012-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3377139Medicaid
TN3709285Medicare UPIN