Provider Demographics
NPI:1659382885
Name:BLUE RIDGE MEDICAL MANAGEMENT CORPORATION
Entity Type:Organization
Organization Name:BLUE RIDGE MEDICAL MANAGEMENT CORPORATION
Other - Org Name:MSMG OB GYN KPT B
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:423-915-5185
Mailing Address - Street 1:PO BOX 3700
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37602-3700
Mailing Address - Country:US
Mailing Address - Phone:866-397-1439
Mailing Address - Fax:423-262-1373
Practice Address - Street 1:2002 BROOKSIDE DR
Practice Address - Street 2:SUITE 200
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-4634
Practice Address - Country:US
Practice Address - Phone:423-246-3500
Practice Address - Fax:423-847-6372
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-11
Last Update Date:2010-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3716291Medicaid
TN3716291Medicaid