Provider Demographics
NPI:1073990248
Name:BLUE RIDGE MEDICAL MANAGMENT CORPORATION
Entity Type:Organization
Organization Name:BLUE RIDGE MEDICAL MANAGMENT CORPORATION
Other - Org Name:BALLAD HEALTH MEDICAL ASSOCIATES
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:423-302-3051
Mailing Address - Street 1:58 CARROLL ST
Mailing Address - Street 2:ROOM 2037
Mailing Address - City:LEBANON
Mailing Address - State:VA
Mailing Address - Zip Code:24266
Mailing Address - Country:US
Mailing Address - Phone:276-883-8062
Mailing Address - Fax:276-883-8064
Practice Address - Street 1:58 CARROLL ST
Practice Address - Street 2:ROOM 2037
Practice Address - City:LEBANON
Practice Address - State:VA
Practice Address - Zip Code:24266
Practice Address - Country:US
Practice Address - Phone:276-883-8062
Practice Address - Fax:276-883-8064
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-27
Last Update Date:2019-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA623221900OtherDEPARTMENT OF LABOR
VAC09112Medicare PIN