NPIMap

Organization Active NPI

Blue Ridge Medical Management Corporation

  • Pediatrics Physician
  • Lebanon, VA
National Provider Identifier
1295903565
Registry record updated Oct 29, 2010
On this page

Key facts

NPPES NPI Registry
Primary specialty
Pediatrics PhysicianTaxonomy code 208000000X
Legal business name
BLUE RIDGE MEDICAL MANAGEMENT CORPORATION
Doing business as
MSMG PEDS LEB
Practice address
344 Overlook Dr
Lebanon, VA 24266-3436
Phone
(276) 889-0201
Fax
(276) 889-0081
NPI assigned
Feb 20, 2008
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 29, 2010

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Carl Steven Kilgore
Title
President
Phone
(423) 915-5116

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Pediatrics PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 208000000X Primary

Addresses

Primary practice location

344 Overlook Dr
Lebanon, VA 24266-3436

Mailing address

PO Box 3700
Johnson City, TN 37602-3700
Phone (866) 397-1439

Other identifiers 1

IdentifierTypeStateIssuer
1295903565MedicaidVA

Other names 1

  • MSMG PEDS LEB Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in VA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
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

National Provider Directory

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1203465600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1288310400000",
    "number": "1295903565",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 3700",
            "city": "JOHNSON CITY",
            "state": "TN",
            "postal_code": "376023700",
            "telephone_number": "866-397-1439",
            "fax_number": "423-262-1373"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "344 OVERLOOK DR",
            "city": "LEBANON",
            "state": "VA",
            "postal_code": "242663436",
            "telephone_number": "276-889-0201",
            "fax_number": "276-889-0081"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "BLUE RIDGE MEDICAL MANAGEMENT CORPORATION",
        "organizational_subpart": "NO",
        "enumeration_date": "2008-02-20",
        "last_updated": "2010-10-29",
        "status": "A",
        "authorized_official_last_name": "KILGORE",
        "authorized_official_first_name": "CARL",
        "authorized_official_middle_name": "STEVEN",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "423-915-5116"
    },
    "taxonomies": [
        {
            "code": "208000000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Pediatrics",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1295903565",
            "state": "VA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "MSMG PEDS LEB",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Lebanon, VA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 29, 2010; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.