Provider Demographics
NPI:1538315452
Name:BLUE RIDGE MEDICAL MANAGEMENT CORPORATION
Entity Type:Organization
Organization Name:BLUE RIDGE MEDICAL MANAGEMENT CORPORATION
Other - Org Name:TRICITIES CANCER CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
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 1:2020 BROOKSIDE DRIVE
Mailing Address - Street 2:SUITE 20
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-4633
Mailing Address - Country:US
Mailing Address - Phone:423-392-4673
Mailing Address - Fax:423-932-4257
Practice Address - Street 1:2020 BROOKSIDE DRIVE
Practice Address - Street 2:SUITE 20
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-4633
Practice Address - Country:US
Practice Address - Phone:423-392-4673
Practice Address - Fax:423-932-4257
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-12
Last Update Date:2010-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical OncologyGroup - Single Specialty
No207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1507568Medicaid
VA1538315452Medicaid
VA1538315452Medicaid