Basic Information
| Provider Information | |||||||||
| NPI: | 1669781993 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | APPALACHIAN EMERGENCY PHYSICIANS | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 534964 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303534950 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8669165259 | ||||||||
| FaxNumber: | 2319224030 | ||||||||
| Practice Location | |||||||||
| Address1: | 312 HOSPITAL DRIVE | ||||||||
| Address2: | |||||||||
| City: | CLINTWOOD | ||||||||
| State: | VA | ||||||||
| PostalCode: | 242280001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8669165259 | ||||||||
| FaxNumber: | 2319224030 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2010 | ||||||||
| LastUpdateDate: | 02/22/2011 | ||||||||
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| AuthorizedOfficialLastName: | KILGORE | ||||||||
| AuthorizedOfficialFirstName: | CARL | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT OF BLUE RIDGE MEDICAL MGT | ||||||||
| AuthorizedOfficialTelephone: | 8669165259 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 7100142630 | 05 | KY | MEDICAID | 1669781993 | 05 | VA | MEDICAID | 6999717 | 05 | NC | MEDICAID |