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Organization
BLUE RIDGE MEDICAL MANAGEMENT CORPORATION
Active
Organization
BLUE RIDGE MEDICAL MANAGEMENT CORPORATION
Active
Other names
MSMG FP IM ERW
Organization subpart
No
Provider details
NPI number
Authorized official
CARL S KILGORE (PRESIDENT)
(423) 915-5121
Entity
Organization
Contact information
Practice address
630 ONEEGA LN, SUITE A, ERWIN, TN 37650-2197
(423) 735-5700
(423) 735-0967
Mailing address
630 ONEEGA LN, SUITE A, ERWIN, TN 37650-2197
(423) 735-5700
(423) 735-0967
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
—
NULL
207Q00000X
Family Medicine Physician
Primary
—
—
207R00000X
Internal Medicine Physician
—
NULL
207R00000X
Internal Medicine Physician
—
—
363LF0000X
Family Nurse Practitioner
—
NULL
363LF0000X
Family Nurse Practitioner
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1568705457
—
VA
01
—
614862405
DEPARTMENT OF LABOR
SD
01
—
CA5744
RR MEDICARE
TN
05
—
Q002802
—
TN
Enumeration date
03/29/2013
Last updated
02/14/2017
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