Provider Demographics
NPI:1326086224
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 1:2000 BROOKSIDE DR
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-4627
Mailing Address - Country:US
Mailing Address - Phone:423-857-5905
Mailing Address - Fax:423-857-5904
Practice Address - Street 1:2000 BROOKSIDE DR
Practice Address - Street 2:3RD FLOOR
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-4627
Practice Address - Country:US
Practice Address - Phone:423-857-5905
Practice Address - Fax:423-857-5904
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-03
Last Update Date:2019-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207R00000X
TN208M00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNCA5744OtherRR MEDICARE
KY7100115300Medicaid
VA1326086224Medicaid
TN3734243Medicaid
NC5912640Medicaid
TN020487805OtherDEPARTMENT OF LABOR
TN4344809OtherBLUECARE
KY7100031020Medicaid
TN020487805OtherDEPARTMENT OF LABOR