=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548552458
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BLUE RIDGE MEDICAL MANAGEMENT CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/11/2011
-----------------------------------------------------
Last Update Date | 06/18/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1020 TERRACE DR SUITE 202
-----------------------------------------------------
City | MARION
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24354-4392
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 276-781-7848
-----------------------------------------------------
Fax | 276-781-7849
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1205 SNIDER ST
-----------------------------------------------------
City | MARION
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24354-4221
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 276-781-7848
-----------------------------------------------------
Fax | 276-781-7849
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. CARL STEVEN KILGORE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 423-915-5116
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------