Provider Demographics
NPI:1912243718
Name:BLUE RIDGE MEDICAL MANAGEMENT CORPORATION
Entity Type:Organization
Organization Name:BLUE RIDGE MEDICAL MANAGEMENT CORPORATION
Other - Org Name:MSMG CARDIOLOGY GREENEVILLE
Other - Org Type:Doing Business As
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:423-915-5000
Mailing Address - Street 1:1406 TUSCULUM BLVD
Mailing Address - Street 2:MOB 2 SUITE 2001 A
Mailing Address - City:GREENEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37745-4332
Mailing Address - Country:US
Mailing Address - Phone:423-787-7425
Mailing Address - Fax:423-797-7482
Practice Address - Street 1:1406 TUSCULUM BLVD
Practice Address - Street 2:MOB 2 SUITE 2001 A
Practice Address - City:GREENEVILLE
Practice Address - State:TN
Practice Address - Zip Code:37745-4332
Practice Address - Country:US
Practice Address - Phone:423-787-7425
Practice Address - Fax:423-797-7482
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-26
Last Update Date:2013-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
=========OtherTAX ID
TN3709285Medicare PIN