Basic Information
| Provider Information | |||||||||
| NPI: | 1144231119 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BLUE RIDGE MEDICAL MANAGEMENT CORPORATION | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | DBA BLUE RIDGE PSYCHIATRY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2300 PAVILION DR | ||||||||
| Address2: | |||||||||
| City: | KINGSPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376604622 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4238575720 | ||||||||
| FaxNumber: | 4238575720 | ||||||||
| Practice Location | |||||||||
| Address1: | 2300 PAVILION DR | ||||||||
| Address2: | |||||||||
| City: | KINGSPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376604622 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4238575720 | ||||||||
| FaxNumber: | 4238575720 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | KILGORE | ||||||||
| AuthorizedOfficialFirstName: | C | ||||||||
| AuthorizedOfficialMiddleName: | STEVEN | ||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4239155185 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 3377134 | 05 | TN | MEDICAID |