1649518309 NPI number — BLUE RIDGE MEDICAL MANAGGEMENT CORPORATION

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649518309 NPI number — BLUE RIDGE MEDICAL MANAGGEMENT CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BLUE RIDGE MEDICAL MANAGGEMENT 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:
1649518309
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:
4600 FORT HENRY DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KINGSPORT
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37663
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-224-3950
Provider Business Mailing Address Fax Number:
423-224-3959

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4600 FORT HENRY DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KINGSPORT
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37663
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-224-3950
Provider Business Practice Location Address Fax Number:
423-224-3959
Provider Enumeration Date:
01/30/2013

Additional Information

			
		

Authorized Official

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

Provider Taxonomy Codes

  • Taxonomy code: 261QU0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1532903 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: CA5744 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 1649518309 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".