Blue Ridge Medical Management Corporation
Organization Active NPI Urology Physician · Abingdon, VA
NPI 1033593249 · NPPES record last updated Feb 14, 2017
Key facts
- NPI
- 1033593249
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Urology Physician 208800000X
- Legal business name
- BLUE RIDGE MEDICAL MANAGEMENT CORPORATION
- Practice address
- 16000 Johnston Memorial Dr
Suite 312D
Abingdon, VA 24211-7664 - Phone
- (276) 783-5400
- Fax
- (276) 783-5521
- NPI assigned
- Jul 17, 2015
- Organization subpart
- No
Authorized official
- Name
- Carl Steven Kilgore
- Title
- President/Ceo
- Phone
- (423) 915-5121
Corporate family (same tax ID) 12
Practitioners 8
-
Chelsey Griffiths, PA-C
-
Shauna M Large, FNP
-
Jenny M Pruitt, PA
-
Brad Lee Bauer, M.D.
-
Jack H Whitaker, MD
-
Lesley Wilcoxson, M.D.
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in VA
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20040715001336 | VA | Part B Supplier - Clinic/Group Practice | 9739099441 |
Receives reassigned benefits from 340 practitioners This NPI is an additional NPI on the enrollment Practice locations: Lebanon, VA; Marion, VA; Meadowview, VA; Norton, VA; Abingdon, VA; Rural Retreat, VA; Big Stone Gap, VA; Abington, VA |
National Provider Directory
- Tax ID family
- Kingsport Internal Medi
Locations
16000 Johnston Memorial Dr
Ste 312D
Abingdon, VA 24211
Phone (276) 258-1000
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Urology Physician |
208800000X | Yes |
Addresses
Primary practice location
16000 Johnston Memorial Dr
Suite 312D
Abingdon, VA 24211-7664
Mailing address
16000 Johnston Memorial Dr
Suite 312D
Abingdon, VA 24211-7664
Phone (276) 783-5400
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1033593249 | Medicaid | VA | |
| 623323300 | Other | VA | DEPARTMENT OF LABOR |
Other names
- MSMG URO ABG A
Other providers in Abingdon, VA
- Blue Mountain Therapy, LLC
- Blue Mountain Therapy, LLC
- Blue Ridge Family Chiropractic, PC
- Blue Ridge Medical Management Corp
- Blue Ridge Medical Management Corporation
- Blue Ridge Medical Management Corporation
- Blue Ridge Medical Management Corporation
- Blue Ridge Medical Management Corporation
- Blue Ridge Medical Management Corporation
- Blue Ridge Medical Management Corporation
All providers in Abingdon, VA · Urology Physician in Virginia
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Feb 14, 2017. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.