Basic Information
| Provider Information | |||||||||
| NPI: | 1063881456 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BLUE RIDGE MEDICAL MANAGEMENT CORPORATION | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | FIRST ASSIST / URGENT CARE - NORTON | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 100 15TH ST NW | ||||||||
| Address2: | SUITE A | ||||||||
| City: | NORTON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 242731616 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2764391840 | ||||||||
| FaxNumber: | 2764391845 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 15TH ST NW | ||||||||
| Address2: | SUITE A | ||||||||
| City: | NORTON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 242731616 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2764391840 | ||||||||
| FaxNumber: | 2764391845 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2015 | ||||||||
| LastUpdateDate: | 02/14/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KILGORE | ||||||||
| AuthorizedOfficialFirstName: | CARL | ||||||||
| AuthorizedOfficialMiddleName: | STEVE | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4239525121 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QU0200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
ID Information
| ID | Type | State | Issuer | Description | 1063881456 | 05 | VA | MEDICAID | 623278800 | 01 | VA | DEPARTMENT OF LABOR | OTHER |