Basic Information
| Provider Information | |||||||||
| NPI: | 1619102167 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BLUE RIDGE MEDICAL MANAGEMENT CORPORATION | ||||||||
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| OtherOrganizationName: | MSMG IM ELIZ | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3700 | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376023700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8663971439 | ||||||||
| FaxNumber: | 4232621373 | ||||||||
| Practice Location | |||||||||
| Address1: | 314 ROGOSIN DR | ||||||||
| Address2: | SUITE B | ||||||||
| City: | ELIZABETHTON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376432904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4235472761 | ||||||||
| FaxNumber: | 4235428621 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2009 | ||||||||
| LastUpdateDate: | 10/29/2010 | ||||||||
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| AuthorizedOfficialLastName: | KILGORE | ||||||||
| AuthorizedOfficialFirstName: | CARL | ||||||||
| AuthorizedOfficialMiddleName: | STEVEN | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4239155185 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1619102167 | 05 | VA | MEDICAID | 1513567 | 05 | TN | MEDICAID |