Provider Demographics
NPI:1992105431
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:423-302-3051
Mailing Address - Street 1:2002 BROOKSIDE DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-4634
Mailing Address - Country:US
Mailing Address - Phone:423-224-3933
Mailing Address - Fax:423-224-3934
Practice Address - Street 1:2002 BROOKSIDE DR
Practice Address - Street 2:SUITE 200
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-4634
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:2014-09-03
Last Update Date:2025-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1992105431Medicaid
TNQ008812Medicaid
TNQ008812Medicaid