Basic Information
| Provider Information | |||||||||
| NPI: | 1548686843 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BLUE RIDGE MEDICAL MANAGEMENT CORPORATION | ||||||||
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| OtherOrganizationName: | MSMG PUL CC JMH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 509 MED TECH PKWY | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376042578 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4233026882 | ||||||||
| FaxNumber: | 4239522147 | ||||||||
| Practice Location | |||||||||
| Address1: | 16000 JOHNSTON MEMORIAL DR | ||||||||
| Address2: | SUITE 112D | ||||||||
| City: | ABINGDON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 242117659 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2762581740 | ||||||||
| FaxNumber: | 2762581745 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/11/2014 | ||||||||
| LastUpdateDate: | 07/08/2015 | ||||||||
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| AuthorizedOfficialLastName: | KILGORE | ||||||||
| AuthorizedOfficialFirstName: | CARL | ||||||||
| AuthorizedOfficialMiddleName: | STEVEN | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4239155100 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0200X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207RP1001X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
| ID | Type | State | Issuer | Description | 1548686843 | 05 | VA | MEDICAID |