Provider Demographics
NPI:1275761538
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/CEO
Authorized Official - Prefix:MR
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 1:1 PROFESSIONAL PARK DR
Mailing Address - Street 2:STE 21
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-6587
Mailing Address - Country:US
Mailing Address - Phone:423-232-6900
Mailing Address - Fax:423-232-6903
Practice Address - Street 1:1 PROFESSIONAL PARK DR
Practice Address - Street 2:STE 21
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-6587
Practice Address - Country:US
Practice Address - Phone:423-232-6900
Practice Address - Fax:423-232-6903
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-25
Last Update Date:2019-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1275761538Medicaid
TNCA5744OtherRAILROAD MEDICARE
TN1516423Medicaid
TN020487822OtherDEPARTMENT OF LABOR
TN3709285Medicare PIN