1659475374 NPI number — BLUE RIDGE MEDICAL MANAGEMENT CORPORATION

Table of content: (NPI 1659475374)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659475374 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:
DBA INDIAN PATH PAVILION
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:
1659475374
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2300 PAVILION 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:
37660-4622
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-392-5500
Provider Business Mailing Address Fax Number:
423-392-5597

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2300 PAVILION 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:
37660-4622
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-392-5500
Provider Business Practice Location Address Fax Number:
423-392-5597
Provider Enumeration Date:
09/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KILGORE
Authorized Official First Name:
C.
Authorized Official Middle Name:
STEVEN
Authorized Official Title or Position:
SENIOR VICE PRESIDENT
Authorized Official Telephone Number:
423-915-5185

Provider Taxonomy Codes

  • Taxonomy code: 2084A0401X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 2084P0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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

  • Identifier: 3716292 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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