Provider Demographics
NPI:1811269640
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:STEVEN
Authorized Official - Last Name:KILGORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-915-5116
Mailing Address - Street 1:7021 WEST LEE HIGHWAY
Mailing Address - Street 2:SUITE B
Mailing Address - City:RURAL RETREAT
Mailing Address - State:VA
Mailing Address - Zip Code:24368
Mailing Address - Country:US
Mailing Address - Phone:276-783-5400
Mailing Address - Fax:276-783-5521
Practice Address - Street 1:7021 WEST LEE HIGHWAY
Practice Address - Street 2:SUITE B
Practice Address - City:RURAL RETREAT
Practice Address - State:VA
Practice Address - Zip Code:24368
Practice Address - Country:US
Practice Address - Phone:276-783-5400
Practice Address - Fax:276-783-5521
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-09
Last Update Date:2017-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024166068363LF0000X
208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1811269640Medicaid
VAC09112Medicare PIN