Basic Information
| Provider Information | |||||||||
| NPI: | 1649518309 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BLUE RIDGE MEDICAL MANAGGEMENT CORPORATION | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | BALLAD HEALTH MEDICAL ASSOCIATES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4600 FORT HENRY DR | ||||||||
| Address2: | |||||||||
| City: | KINGSPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37663 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232243950 | ||||||||
| FaxNumber: | 4232243959 | ||||||||
| Practice Location | |||||||||
| Address1: | 4600 FORT HENRY DR | ||||||||
| Address2: | |||||||||
| City: | KINGSPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37663 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232243950 | ||||||||
| FaxNumber: | 4232243959 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2013 | ||||||||
| LastUpdateDate: | 03/29/2019 | ||||||||
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| AuthorizedOfficialLastName: | KILGORE | ||||||||
| AuthorizedOfficialFirstName: | CARL | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4233023051 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QU0200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
ID Information
| ID | Type | State | Issuer | Description | 1532903 | 05 | TN | MEDICAID | CA5744 | 01 | TN | RAILROAD MEDICARE | OTHER | 1649518309 | 05 | VA | MEDICAID |