Provider Demographics
NPI:1396049938
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:S
Authorized Official - Last Name:KILGORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-915-5100
Mailing Address - Street 1:2204 PAVILION DR
Mailing Address - Street 2:SUITE 210
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-4657
Mailing Address - Country:US
Mailing Address - Phone:423-224-3933
Mailing Address - Fax:423-224-3934
Practice Address - Street 1:2204 PAVILION DR
Practice Address - Street 2:SUITE 210
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-4657
Practice Address - Country:US
Practice Address - Phone:423-224-3933
Practice Address - Fax:423-224-3934
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-22
Last Update Date:2010-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty