Provider Demographics
NPI:1891958617
Name:BLUE RIDGE MEDICAL MANAGEMENT CORPORATION
Entity Type:Organization
Organization Name:BLUE RIDGE MEDICAL MANAGEMENT CORPORATION
Other - Org Name:MSMG IM LEB
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: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 1:71 SOUTH FLANNAGAN AVE
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:VA
Practice Address - Zip Code:24266-4515
Practice Address - Country:US
Practice Address - Phone:276-883-8030
Practice Address - Fax:276-883-8034
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-02
Last Update Date:2010-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1891958617Medicaid
VA1891958617Medicaid