Basic Information
| Provider Information | |||||||||
| NPI: | 1508223116 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BLUE RIDGE MEDICAL MANAGEMENT CORPORATION | ||||||||
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| OtherOrganizationName: | MSMG GENERAL SURGERY MARION | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 509 MEDTECH PKWY | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4239522122 | ||||||||
| FaxNumber: | 4239522145 | ||||||||
| Practice Location | |||||||||
| Address1: | 1616 N MAIN ST | ||||||||
| Address2: | SUITE 100 B | ||||||||
| City: | MARION | ||||||||
| State: | VA | ||||||||
| PostalCode: | 243544398 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2767837287 | ||||||||
| FaxNumber: | 2767837786 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/27/2016 | ||||||||
| LastUpdateDate: | 01/27/2016 | ||||||||
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| AuthorizedOfficialLastName: | KILGORE | ||||||||
| AuthorizedOfficialFirstName: | CARL | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4239155121 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
No ID Information.