Provider Demographics
NPI:1467833673
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:423-302-3051
Mailing Address - Street 1:1497 W ELK AVE
Mailing Address - Street 2:SUITE 11
Mailing Address - City:ELIZABETHTON
Mailing Address - State:TN
Mailing Address - Zip Code:37643-2895
Mailing Address - Country:US
Mailing Address - Phone:423-542-8929
Mailing Address - Fax:423-542-8621
Practice Address - Street 1:1497 W ELK AVE
Practice Address - Street 2:SUITE 11
Practice Address - City:ELIZABETHTON
Practice Address - State:TN
Practice Address - Zip Code:37643-2895
Practice Address - Country:US
Practice Address - Phone:423-542-8929
Practice Address - Fax:423-542-8621
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-12
Last Update Date:2019-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ013904Medicaid
TN3709285Medicare PIN