Provider Demographics
NPI:1811380520
Name:BLUE RIDGE MEDICAL MANAGEMENT
Entity Type:Organization
Organization Name:BLUE RIDGE MEDICAL MANAGEMENT
Other - Org Name:MSMG GEN SURG ERWIN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CARL
Authorized Official - Middle Name:STEPHEN
Authorized Official - Last Name:KILGORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-915-5116
Mailing Address - Street 1:630 ONEEGA LN
Mailing Address - Street 2:SUITE D
Mailing Address - City:ERWIN
Mailing Address - State:TN
Mailing Address - Zip Code:37650-2197
Mailing Address - Country:US
Mailing Address - Phone:423-542-7440
Mailing Address - Fax:423-542-7445
Practice Address - Street 1:630 ONEEGA LN
Practice Address - Street 2:SUITE D
Practice Address - City:ERWIN
Practice Address - State:TN
Practice Address - Zip Code:37650-2197
Practice Address - Country:US
Practice Address - Phone:423-542-7440
Practice Address - Fax:423-542-7445
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-05
Last Update Date:2017-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ012234Medicaid
TNQ012234Medicaid