Provider Demographics
NPI:1215048368
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:PO BOX 3700
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37602-3700
Mailing Address - Country:US
Mailing Address - Phone:866-397-1439
Mailing Address - Fax:423-262-1373
Practice Address - Street 1:438 E VANN RD
Practice Address - Street 2:SUITE 200
Practice Address - City:GREENEVILLE
Practice Address - State:TN
Practice Address - Zip Code:37743-7202
Practice Address - Country:US
Practice Address - Phone:423-278-1704
Practice Address - Fax:423-278-1806
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2010-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3719387Medicaid
TN3719387Medicaid