Provider Demographics
NPI:1164966909
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
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 1:245 MEDICAL PARK DR
Mailing Address - Street 2:SUITE E
Mailing Address - City:MARION
Mailing Address - State:VA
Mailing Address - Zip Code:24354-1100
Mailing Address - Country:US
Mailing Address - Phone:276-258-3600
Mailing Address - Fax:276-258-3605
Practice Address - Street 1:245 MEDICAL PARK DR
Practice Address - Street 2:SUITE E
Practice Address - City:MARION
Practice Address - State:VA
Practice Address - Zip Code:24354-1100
Practice Address - Country:US
Practice Address - Phone:276-258-3600
Practice Address - Fax:276-258-3605
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-13
Last Update Date:2019-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1164966909Medicaid