Basic Information
Provider Information | |||||||||
NPI: | 1912137506 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | BLUE RIDGE MEDICAL MANAGEMENT CORPORATION | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | BALLAD HEALTH MEDICAL ASSOCIATES | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 408 N STATE OF FRANKLIN RD | ||||||||
Address2: | SUITE 24 | ||||||||
City: | JOHNSON CITY | ||||||||
State: | TN | ||||||||
PostalCode: | 376046089 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4234311810 | ||||||||
FaxNumber: | 4234311811 | ||||||||
Practice Location | |||||||||
Address1: | 408 N STATE OF FRANKLIN RD | ||||||||
Address2: | SUITE 24 | ||||||||
City: | JOHNSON CITY | ||||||||
State: | TN | ||||||||
PostalCode: | 376046089 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4234311810 | ||||||||
FaxNumber: | 4234311811 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/17/2009 | ||||||||
LastUpdateDate: | 03/29/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | KILGORE | ||||||||
AuthorizedOfficialFirstName: | CARL | ||||||||
AuthorizedOfficialMiddleName: | STEVEN | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 4233023051 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   | 207R00000X |   | TN | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |   | 208M00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Hospitalist |   |
ID Information
ID | Type | State | Issuer | Description | 020487819 | 01 | TN | DEPARTMENT OF LABOR | OTHER | 7100104590 | 05 | KY |   | MEDICAID | 1515079 | 05 | TN |   | MEDICAID | 1912137506 | 05 | VA |   | MEDICAID | 5912773 | 05 | NC |   | MEDICAID | CA5744 | 01 | TN | RR MEDICARE | OTHER | 4344857 | 01 | TN | BLUECARE | OTHER | 7100117550 | 05 | KY |   | MEDICAID |