Provider Demographics
NPI:1134139017
Name:BLUE RIDGE MEDICAL MANAGEMENT CORPORATION
Entity Type:Organization
Organization Name:BLUE RIDGE MEDICAL MANAGEMENT CORPORATION
Other - Org Name:DBA EAST TENNESSEE OB/GYN ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SENIOR VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:C
Authorized Official - Middle Name:STEVEN
Authorized Official - Last Name:KILGORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-915-9185
Mailing Address - Street 1:900 W. MAIN STREET
Mailing Address - Street 2:HEALTH LINK OF ROGERSVILLE
Mailing Address - City:ROGERSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37657
Mailing Address - Country:US
Mailing Address - Phone:423-272-0542
Mailing Address - Fax:423-272-0544
Practice Address - Street 1:900 W MAIN ST
Practice Address - Street 2:HEALTH LINK OF ROGERSVILLE
Practice Address - City:ROGERSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37857-2448
Practice Address - Country:US
Practice Address - Phone:423-272-0542
Practice Address - Fax:423-272-0544
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3716290Medicaid
TN3716290Medicaid