Provider Demographics
NPI:1063881456
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:STEVE
Authorized Official - Last Name:KILGORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-952-5121
Mailing Address - Street 1:100 15TH ST NW
Mailing Address - Street 2:SUITE A
Mailing Address - City:NORTON
Mailing Address - State:VA
Mailing Address - Zip Code:24273-1616
Mailing Address - Country:US
Mailing Address - Phone:276-439-1840
Mailing Address - Fax:276-439-1845
Practice Address - Street 1:100 15TH ST NW
Practice Address - Street 2:SUITE A
Practice Address - City:NORTON
Practice Address - State:VA
Practice Address - Zip Code:24273-1616
Practice Address - Country:US
Practice Address - Phone:276-439-1840
Practice Address - Fax:276-439-1845
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-16
Last Update Date:2017-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1063881456Medicaid
VA623278800OtherDEPARTMENT OF LABOR
VAC09112Medicare PIN