Provider Demographics
NPI:1982882379
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:423-915-5234
Mailing Address - Street 1:1101 E STONE DR
Mailing Address - Street 2:SUITE 2
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-3384
Mailing Address - Country:US
Mailing Address - Phone:423-246-7259
Mailing Address - Fax:423-246-7205
Practice Address - Street 1:1101 E STONE DR
Practice Address - Street 2:SUITE 2
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-3384
Practice Address - Country:US
Practice Address - Phone:423-246-7259
Practice Address - Fax:423-246-7205
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-07
Last Update Date:2010-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3735664Medicaid
TN3709285Medicare PIN