Provider Demographics
NPI:1205249885
Name:BLUE RIDGE MEDICAL MANAGEMENT CORPORATION
Entity type:Organization
Organization Name:BLUE RIDGE MEDICAL MANAGEMENT CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
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 1:444 CLINCHFIELD ST
Mailing Address - Street 2:UNIT 201
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-3858
Mailing Address - Country:US
Mailing Address - Phone:423-857-7650
Mailing Address - Fax:423-857-7655
Practice Address - Street 1:444 CLINCHFIELD ST
Practice Address - Street 2:UNIT 201
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-3858
Practice Address - Country:US
Practice Address - Phone:423-857-7650
Practice Address - Fax:423-857-7655
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-11
Last Update Date:2019-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1205249885Medicaid
TNQ009978Medicaid
VA1205249885Medicaid