1487765624 NPI number — BLUE RIDGE MEDICAL MANAGEMENT CORPORATION

Table of content: (NPI 1487765624)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487765624 NPI number — BLUE RIDGE MEDICAL MANAGEMENT CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BLUE RIDGE MEDICAL MANAGEMENT CORPORATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
BALLAD HEALTH MEDICAL ASSOCIATES
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1487765624
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/29/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
98 15TH ST NW STE 207
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORTON
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24273-1600
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
276-439-1490
Provider Business Mailing Address Fax Number:
276-439-1495

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
98 15TH ST NW STE 207
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORTON
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24273-1600
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
276-439-1490
Provider Business Practice Location Address Fax Number:
276-439-1495
Provider Enumeration Date:
08/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KILGORE
Authorized Official First Name:
C
Authorized Official Middle Name:
STEVEN
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
423-302-3051

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 020487802 . This is a "DEPARTMENT OF LABOR" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 1487765624 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: DF7910 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( VI ) . This identifiers is of the category "OTHER".
  • Identifier: 7100074010 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7100133630 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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