Provider Demographics
NPI:1639463490
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:CARL
Authorized Official - Middle Name:STEVEN
Authorized Official - Last Name:KILGORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-302-3051
Mailing Address - Street 1:245 MEDICAL PARK DR
Mailing Address - Street 2:FIRST FLOOR
Mailing Address - City:MARION
Mailing Address - State:VA
Mailing Address - Zip Code:24354-1100
Mailing Address - Country:US
Mailing Address - Phone:276-378-1341
Mailing Address - Fax:276-378-1205
Practice Address - Street 1:245 MEDICAL PARK DR
Practice Address - Street 2:FIRST FLOOR
Practice Address - City:MARION
Practice Address - State:VA
Practice Address - Zip Code:24354-1100
Practice Address - Country:US
Practice Address - Phone:276-378-1341
Practice Address - Fax:276-378-1205
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-08
Last Update Date:2019-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VADT9105OtherRAILROAD MEDICARE
TNQ002125Medicaid
VA622799700OtherDEPARTMENT OF LABOR
VA1639463490Medicaid
TNQ002125Medicaid