Provider Demographics
NPI:1184926719
Name:BLUE RIDGE MEDICAL MANAGEMENT C ORPORATION
Entity type:Organization
Organization Name:BLUE RIDGE MEDICAL MANAGEMENT C ORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:CARL
Authorized Official - Middle Name:STEVEN
Authorized Official - Last Name:KILGORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-915-5185
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:886-639-7143
Mailing Address - Fax:423-262-1373
Practice Address - Street 1:1497 W ELK AVE
Practice Address - Street 2:SUITE 20
Practice Address - City:ELIZABETHTON
Practice Address - State:TN
Practice Address - Zip Code:37643-2874
Practice Address - Country:US
Practice Address - Phone:423-547-2762
Practice Address - Fax:423-542-8621
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-02
Last Update Date:2010-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3709285Medicare PIN