Provider Demographics
NPI:1629310115
Name:BLUE RIDGE MEDICAL MANAGEMENT CORPORATION
Entity Type:Organization
Organization Name:BLUE RIDGE MEDICAL MANAGEMENT CORPORATION
Other - Org Name:MSMG IM UNI
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:423-952-2122
Mailing Address - Street 1:509 MED TECH PKWY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-2578
Mailing Address - Country:US
Mailing Address - Phone:423-952-2122
Mailing Address - Fax:423-952-2147
Practice Address - Street 1:3614 UNICOI DR
Practice Address - Street 2:
Practice Address - City:UNICOI
Practice Address - State:TN
Practice Address - Zip Code:37692-6860
Practice Address - Country:US
Practice Address - Phone:423-743-7151
Practice Address - Fax:423-743-7059
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-22
Last Update Date:2015-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1532914Medicaid
TN020487840OtherDEPT OF LABOR
TNCA5744OtherRR MEDICARE
TN1532914Medicaid