Provider Demographics
NPI:1215395843
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 1:1616 N MAIN ST
Mailing Address - Street 2:STE 100A
Mailing Address - City:MARION
Mailing Address - State:VA
Mailing Address - Zip Code:24354-4473
Mailing Address - Country:US
Mailing Address - Phone:276-783-9752
Mailing Address - Fax:276-783-7786
Practice Address - Street 1:1616 N MAIN ST
Practice Address - Street 2:STE 100A
Practice Address - City:MARION
Practice Address - State:VA
Practice Address - Zip Code:24354-4473
Practice Address - Country:US
Practice Address - Phone:276-783-9752
Practice Address - Fax:276-783-7786
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-10
Last Update Date:2019-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA020487804OtherDEPARTMENT OF LABOR
VA1215395843Medicaid
VA1215395843Medicaid