1659382885 NPI number — BLUE RIDGE MEDICAL MANAGEMENT CORPORATION

Table of content: (NPI 1659382885)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659382885 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:
MSMG OB GYN KPT B
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:
1659382885
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/27/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3700
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JOHNSON CITY
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37602-3700
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
866-397-1439
Provider Business Mailing Address Fax Number:
423-262-1373

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2002 BROOKSIDE DR
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
KINGSPORT
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37660-4634
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-246-3500
Provider Business Practice Location Address Fax Number:
423-847-6372
Provider Enumeration Date:
08/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KILGORE
Authorized Official First Name:
CARL
Authorized Official Middle Name:
STEVEN
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
423-915-5185

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3716291 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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