Provider Demographics
NPI:1912318635
Name:BLUE RIDGE MEDICAL MANAGEMENT CORPORATION
Entity Type:Organization
Organization Name:BLUE RIDGE MEDICAL MANAGEMENT CORPORATION
Other - Org Name:MSMG HIMA UCMH
Other - Org Type:Doing Business As
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:423-915-5100
Mailing Address - Street 1:100 GREENWAY CIR
Mailing Address - Street 2:
Mailing Address - City:ERWIN
Mailing Address - State:TN
Mailing Address - Zip Code:37650-2177
Mailing Address - Country:US
Mailing Address - Phone:423-431-1810
Mailing Address - Fax:423-431-1811
Practice Address - Street 1:100 GREENWAY CIR
Practice Address - Street 2:
Practice Address - City:ERWIN
Practice Address - State:TN
Practice Address - Zip Code:37650-2177
Practice Address - Country:US
Practice Address - Phone:423-431-1810
Practice Address - Fax:423-431-1811
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-15
Last Update Date:2014-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1912318635Medicaid
TNQ006137Medicaid
VA1912318635Medicaid
TN=========171OtherTRICARE