Provider Demographics
NPI:1386028215
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 1:400 N STATE OF FRANKLIN RD
Mailing Address - Street 2:OFFICE OF NISWONGER CEO
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-6035
Mailing Address - Country:US
Mailing Address - Phone:423-431-4847
Mailing Address - Fax:423-431-3949
Practice Address - Street 1:400 N STATE OF FRANKLIN RD
Practice Address - Street 2:OFFICE OF NISWONGER CEO
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-6035
Practice Address - Country:US
Practice Address - Phone:423-431-4847
Practice Address - Fax:423-431-3949
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-09
Last Update Date:2019-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1386028215Medicaid
VA1386028215Medicaid
TNQ013912Medicaid
NC1386028215Medicaid