Provider Demographics
NPI:1467575001
Name:BLUE RIDGE MEDICAL MANAGEMENT CORPORATION
Entity Type:Organization
Organization Name:BLUE RIDGE MEDICAL MANAGEMENT CORPORATION
Other - Org Name:MSMG FP IM KPT
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:423-915-5185
Mailing Address - Street 1:2202 N JOHN B DENNIS PKWY
Mailing Address - Street 2:SUITE 204
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-5887
Mailing Address - Country:US
Mailing Address - Phone:423-229-7777
Mailing Address - Fax:423-229-7776
Practice Address - Street 1:2202 N JOHN B DENNIS HWY
Practice Address - Street 2:SUITE 204
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-5904
Practice Address - Country:US
Practice Address - Phone:423-229-7777
Practice Address - Fax:423-229-7776
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-09
Last Update Date:2011-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3716296Medicaid
TN3709285Medicare PIN