Basic Information
| Provider Information | |||||||||
| NPI: | 1578994653 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BLUE RIDGE MEDICAL MANAGEMENT CORPORATION | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MSMG URO ABG A | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 16000 JOHNSTON MEMORIAL DR | ||||||||
| Address2: | SUITE 112C | ||||||||
| City: | ABINGDON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 242117659 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4239522122 | ||||||||
| FaxNumber: | 2762581745 | ||||||||
| Practice Location | |||||||||
| Address1: | 16000 JOHNSTON MEMORIAL DR | ||||||||
| Address2: | SUITE 112C | ||||||||
| City: | ABINGDON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 242117659 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2762581740 | ||||||||
| FaxNumber: | 2762581745 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/27/2013 | ||||||||
| LastUpdateDate: | 07/09/2015 | ||||||||
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| AuthorizedOfficialLastName: | KILGORE | ||||||||
| AuthorizedOfficialFirstName: | CARL | ||||||||
| AuthorizedOfficialMiddleName: | STEVEN | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4239155116 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.