1568705457 NPI number — BLUE RIDGE MEDICAL MANAGEMENT CORPORATION

Table of content: (NPI 1568705457)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568705457 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 FP IM ERW
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:
1568705457
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/14/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
630 ONEEGA LN
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
ERWIN
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37650-2197
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-735-5700
Provider Business Mailing Address Fax Number:
423-735-0967

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
630 ONEEGA LN
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
ERWIN
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37650-2197
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-735-5700
Provider Business Practice Location Address Fax Number:
423-735-0967
Provider Enumeration Date:
03/29/2013

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:
423-915-5121

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: CA5744 . This is a "RR MEDICARE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 614862405 . This is a "DEPARTMENT OF LABOR" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: Q002802 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1568705457 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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