Provider Demographics
NPI:1447543996
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:STEVEN
Authorized Official - Last Name:KILGORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-302-3051
Mailing Address - Street 1:7021 WEST LEE HIGHWAY
Mailing Address - Street 2:SUITE C
Mailing Address - City:RURAL RETREAT
Mailing Address - State:VA
Mailing Address - Zip Code:24368
Mailing Address - Country:US
Mailing Address - Phone:866-595-3662
Mailing Address - Fax:276-686-6046
Practice Address - Street 1:7021 WEST LEE HIGHWAY
Practice Address - Street 2:SUITE C
Practice Address - City:RURAL RETREAT
Practice Address - State:VA
Practice Address - Zip Code:24368
Practice Address - Country:US
Practice Address - Phone:866-595-3662
Practice Address - Fax:276-686-6046
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-17
Last Update Date:2019-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA020487814OtherDEPARTMENT OF LABOR
VA1447543996Medicaid
VAC09112Medicare PIN