Provider Demographics
NPI:1255634564
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
Authorized Official - Prefix:
Authorized Official - First Name:CARL
Authorized Official - Middle Name:S
Authorized Official - Last Name:KILGORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-302-3051
Mailing Address - Street 1:1497 WEST ELK AVE
Mailing Address - Street 2:SUITE 21
Mailing Address - City:ELIZABETHTON
Mailing Address - State:TN
Mailing Address - Zip Code:37643
Mailing Address - Country:US
Mailing Address - Phone:423-542-7420
Mailing Address - Fax:423-542-7425
Practice Address - Street 1:1497 WEST ELK AVE
Practice Address - Street 2:SUITE 21
Practice Address - City:ELIZABETHTON
Practice Address - State:TN
Practice Address - Zip Code:37643
Practice Address - Country:US
Practice Address - Phone:423-542-7420
Practice Address - Fax:423-542-7425
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-08
Last Update Date:2019-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1526580Medicaid
TN020487839OtherDEPARTMENT OF LABOR
VA1255634564Medicaid
TN020487839OtherDEPARTMENT OF LABOR