Provider Demographics
NPI:1063704765
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:MR
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 1:1118 SNIDER ST
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:VA
Mailing Address - Zip Code:24354-4216
Mailing Address - Country:US
Mailing Address - Phone:276-783-5148
Mailing Address - Fax:276-783-6716
Practice Address - Street 1:1118 SNIDER ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:VA
Practice Address - Zip Code:24354-4216
Practice Address - Country:US
Practice Address - Phone:276-783-5148
Practice Address - Fax:276-783-6716
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-12
Last Update Date:2011-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty