Provider Demographics
NPI:1659476992
Name:BLUE RIDGE MEDICAL MANAGEMENT CORPORATION
Entity Type:Organization
Organization Name:BLUE RIDGE MEDICAL MANAGEMENT CORPORATION
Other - Org Name:DBA INDIAN PATH MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SENIOR VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:C.
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 1:2000 BROOKSIDE DR
Mailing Address - Street 2:7TH FLOOR GERIATRIC PSYCHIC UNIT
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-4627
Mailing Address - Country:US
Mailing Address - Phone:423-857-7740
Mailing Address - Fax:423-857-7711
Practice Address - Street 1:2000 BROOKSIDE DR
Practice Address - Street 2:7TH FLOOR GERIATRIC PSYCHIC UNIT
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-4627
Practice Address - Country:US
Practice Address - Phone:423-857-7740
Practice Address - Fax:423-857-7711
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3732722Medicaid
TN3732722Medicare ID - Type Unspecified