Provider Demographics
NPI:1467896597
Name:BLUE RIDGE MEDICAL MANAGEMENT CORPORATION
Entity Type:Organization
Organization Name:BLUE RIDGE MEDICAL MANAGEMENT CORPORATION
Other - Org Name:MSMG VAS SURG ABG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
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:423-915-5121
Mailing Address - Street 1:16000 JOHNSTON MEMORIAL DR
Mailing Address - Street 2:SUITE 212 C
Mailing Address - City:ABINGDON
Mailing Address - State:VA
Mailing Address - Zip Code:24211-7659
Mailing Address - Country:US
Mailing Address - Phone:276-258-2014
Mailing Address - Fax:276-258-3745
Practice Address - Street 1:16000 JOHNSTON MEMORIAL DR
Practice Address - Street 2:SUITE 212 C
Practice Address - City:ABINGDON
Practice Address - State:VA
Practice Address - Zip Code:24211-7659
Practice Address - Country:US
Practice Address - Phone:276-258-2014
Practice Address - Fax:276-258-3745
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-19
Last Update Date:2017-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1467896597Medicaid
VA622524600OtherDEPARTMENT OF LABOR/BLACK LUNG & ENERGY
VA1467896597Medicaid