Basic Information
| Provider Information | |||||||||
| NPI: | 1700264900 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BLUE RIDGE MEDICAL MANAGEMENT CORPORATION | ||||||||
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| OtherOrganizationName: | BALLAD HEALTH MEDICAL ASSOCIATES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 16000 JOHNSTON MEMORIAL DR | ||||||||
| Address2: | SUITE 112 | ||||||||
| City: | ABINGDON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 242117664 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2762583780 | ||||||||
| FaxNumber: | 2762583776 | ||||||||
| Practice Location | |||||||||
| Address1: | 16000 JOHNSTON MEMORIAL DR | ||||||||
| Address2: | SUITE 112 | ||||||||
| City: | ABINGDON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 242117664 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2762583780 | ||||||||
| FaxNumber: | 2762583776 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2015 | ||||||||
| LastUpdateDate: | 03/29/2019 | ||||||||
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| AuthorizedOfficialLastName: | KILGORE | ||||||||
| AuthorizedOfficialFirstName: | CARL | ||||||||
| AuthorizedOfficialMiddleName: | STEVE | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4233023051 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RE0101X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism |
ID Information
| ID | Type | State | Issuer | Description | DF7910 | 01 | VA | RAILROAD MEDICARE | OTHER | 1700264900 | 05 | VA | MEDICAID |