Provider Demographics
NPI:1225332067
Name:BLUE RIDGE MEDICAL MANAGEMENT CORPORATION
Entity Type:Organization
Organization Name:BLUE RIDGE MEDICAL MANAGEMENT CORPORATION
Other - Org Name:MSMG OB GYN GRAY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT BRMMC
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 1:203 GRAY COMMONS CIR
Mailing Address - Street 2:SUITE B
Mailing Address - City:GRAY
Mailing Address - State:TN
Mailing Address - Zip Code:37615-5407
Mailing Address - Country:US
Mailing Address - Phone:423-392-6370
Mailing Address - Fax:423-392-6081
Practice Address - Street 1:203 GRAY COMMONS CIR
Practice Address - Street 2:SUITE B
Practice Address - City:GRAY
Practice Address - State:TN
Practice Address - Zip Code:37615-5407
Practice Address - Country:US
Practice Address - Phone:423-392-6370
Practice Address - Fax:423-392-6081
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-10
Last Update Date:2011-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNPENDINGMedicare PIN