Provider Demographics
NPI:1689053753
Name:BLUE RIDGE MEDICAL MANAGEMENT
Entity Type:Organization
Organization Name:BLUE RIDGE MEDICAL MANAGEMENT
Other - Org Name:REGIONAL CANCER CENTER AT SSH
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:423-915-5116
Mailing Address - Street 1:1497 W ELK AVE
Mailing Address - Street 2:SUITE 20B
Mailing Address - City:ELIZABETHTON
Mailing Address - State:TN
Mailing Address - Zip Code:37643-2895
Mailing Address - Country:US
Mailing Address - Phone:423-232-6900
Mailing Address - Fax:423-232-6903
Practice Address - Street 1:1497 W ELK AVE
Practice Address - Street 2:SUITE 20B
Practice Address - City:ELIZABETHTON
Practice Address - State:TN
Practice Address - Zip Code:37643-2895
Practice Address - Country:US
Practice Address - Phone:423-232-6900
Practice Address - Fax:423-232-6903
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-22
Last Update Date:2015-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3709285Medicare PIN