Blue Ridge Medical Management Corporation
Organization Active NPI Surgery Physician · Mountain City, TN
NPI 1063783751 · NPPES record last updated Feb 14, 2017
Key facts
- NPI
- 1063783751
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Surgery Physician 208600000X
- Legal business name
- BLUE RIDGE MEDICAL MANAGEMENT CORPORATION
- Practice address
- 1901 S Shady St
Mountain City, TN 37683-2021 - Phone
- (423) 727-1139
- Fax
- (423) 727-1173
- NPI assigned
- Jan 26, 2012
- Organization subpart
- No
Authorized official
- Name
- Carl Steven Kilgore
- Title
- Ceo
- Phone
- (423) 915-5116
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in TN
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20031204000996 | TN | Part B Supplier - Clinic/Group Practice | 9739099441 |
Receives reassigned benefits from 562 practitioners This NPI is an additional NPI on the enrollment Practice locations: Johnson City, TN; Kingsport, TN; Mountain City, TN; Elizabethton, TN; Erwin, TN; Greeneville, TN |
National Provider Directory
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Surgery Physician |
208600000X | Yes |
Addresses
Primary practice location
1901 S Shady St
Mountain City, TN 37683-2021
Mailing address
1901 S Shady St
Mountain City, TN 37683-2021
Phone (423) 727-1139
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1063783751 | Medicaid | VA | |
| 1527050 | Medicaid | TN |
Other names
- MSMG GEN SURG MTN
Other providers in Mountain City, TN
- Angela Berardi
- Bio-Medical Applications of Tennessee, Inc.
- Caleigh Blair
- Reshana D Blevins
- Blue Ridge Medical Management Corpoartion
- Blue Ridge Medical Management Corporation
- Blue Ridge Medical Management Corporation
- Blue Ridge Medical Management Corporation
- Blue Ridge Senior Living
- Sara Boles
All providers in Mountain City, TN · Surgery Physician in Tennessee
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.