Provider Demographics
NPI:1790167351
Name:BLUE RIDGE MEDICAL MANAGEMENT
Entity Type:Organization
Organization Name:BLUE RIDGE MEDICAL MANAGEMENT
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 1:58 CARROLL STREET
Mailing Address - Street 2:SUITE 2D
Mailing Address - City:LEBANON
Mailing Address - State:VA
Mailing Address - Zip Code:24266
Mailing Address - Country:US
Mailing Address - Phone:276-883-8091
Mailing Address - Fax:276-883-8090
Practice Address - Street 1:58 CARROLL STREET
Practice Address - Street 2:SUITE 2D
Practice Address - City:LEBANON
Practice Address - State:VA
Practice Address - Zip Code:24266
Practice Address - Country:US
Practice Address - Phone:276-883-8091
Practice Address - Fax:276-883-8090
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-19
Last Update Date:2019-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1790167351Medicaid
VA020487828OtherDEPARTMENT OF LABOR
VA020487828OtherDEPARTMENT OF LABOR