Provider Demographics
NPI:1598995789
Name:BLUE RIDGE MEDICAL MANAGEMENT CORPORATION
Entity Type:Organization
Organization Name:BLUE RIDGE MEDICAL MANAGEMENT CORPORATION
Other - Org Name:BALLAD HEALTH MEDICAL ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:CARL
Authorized Official - Last Name:KILGORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-302-3051
Mailing Address - Street 1:2205 PAVILION DR STE 101
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-4641
Mailing Address - Country:US
Mailing Address - Phone:423-857-6466
Mailing Address - Fax:423-857-6456
Practice Address - Street 1:2205 PAVILION DR
Practice Address - Street 2:SUITE 101
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-4641
Practice Address - Country:US
Practice Address - Phone:423-857-6466
Practice Address - Fax:423-857-6456
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-22
Last Update Date:2019-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1516429Medicaid
VA1598995789Medicaid
TN1516429Medicaid