Provider Demographics
NPI:1215082730
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:C
Authorized Official - Middle Name:STEVEN
Authorized Official - Last Name:KILGORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-302-3051
Mailing Address - Street 1:310 N STATE OF FRANKLIN RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-6008
Mailing Address - Country:US
Mailing Address - Phone:423-929-7393
Mailing Address - Fax:423-929-0872
Practice Address - Street 1:310 N STATE OF FRANKLIN RD
Practice Address - Street 2:SUITE 101
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-6008
Practice Address - Country:US
Practice Address - Phone:423-929-7393
Practice Address - Fax:423-929-0872
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2019-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Single Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3732723Medicaid
KY7100008280Medicaid
KY7100170580Medicaid
TNDF7910OtherRAILROAD MEDICARE
TN020487811OtherDEPARTMENT OF LABOR/FECA
VA1215082730Medicaid
TN3709285Medicare PIN