Provider Demographics
NPI:1568705457
Name:BLUE RIDGE MEDICAL MANAGEMENT CORPORATION
Entity Type:Organization
Organization Name:BLUE RIDGE MEDICAL MANAGEMENT CORPORATION
Other - Org Name:MSMG FP IM ERW
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CARL
Authorized Official - Middle Name:S
Authorized Official - Last Name:KILGORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-915-5121
Mailing Address - Street 1:630 ONEEGA LN
Mailing Address - Street 2:SUITE A
Mailing Address - City:ERWIN
Mailing Address - State:TN
Mailing Address - Zip Code:37650-2197
Mailing Address - Country:US
Mailing Address - Phone:423-735-5700
Mailing Address - Fax:423-735-0967
Practice Address - Street 1:630 ONEEGA LN
Practice Address - Street 2:SUITE A
Practice Address - City:ERWIN
Practice Address - State:TN
Practice Address - Zip Code:37650-2197
Practice Address - Country:US
Practice Address - Phone:423-735-5700
Practice Address - Fax:423-735-0967
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-29
Last Update Date:2017-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNCA5744OtherRR MEDICARE
SD614862405OtherDEPARTMENT OF LABOR
TNQ002802Medicaid
VA1568705457Medicaid
VA1568705457Medicaid