Provider Demographics
NPI:1407866742
Name:BLUE RIDGE MEDICAL MANAGEMENT CORPORATION
Entity Type:Organization
Organization Name:BLUE RIDGE MEDICAL MANAGEMENT CORPORATION
Other - Org Name:MSMG ORTHO MTN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:C
Authorized Official - Middle Name:STEVEN
Authorized Official - Last Name:KILGORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-915-5100
Mailing Address - Street 1:1901 S SHADY ST
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37683-2021
Mailing Address - Country:US
Mailing Address - Phone:423-727-1139
Mailing Address - Fax:423-727-1173
Practice Address - Street 1:1901 S SHADY ST
Practice Address - Street 2:
Practice Address - City:MOUNTAIN CITY
Practice Address - State:TN
Practice Address - Zip Code:37683-2021
Practice Address - Country:US
Practice Address - Phone:423-727-1139
Practice Address - Fax:423-727-1173
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-09
Last Update Date:2010-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1514742Medicaid
TN3719389Medicare PIN