Provider Demographics
NPI:1922124106
Name:PERRY, ALVIS TEDERRALL (MD)
Entity Type:Individual
Prefix:
First Name:ALVIS
Middle Name:TEDERRALL
Last Name:PERRY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 SIMS BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:COMMERCE
Mailing Address - State:GA
Mailing Address - Zip Code:30530-6868
Mailing Address - Country:US
Mailing Address - Phone:229-339-4330
Mailing Address - Fax:706-335-2257
Practice Address - Street 1:3840 PEACHTREE INDUSTRIAL BLVD
Practice Address - Street 2:SUITE 220
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-5031
Practice Address - Country:US
Practice Address - Phone:770-331-3171
Practice Address - Fax:706-335-2257
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2016-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA034921207L00000X, 208VP0014X
TN14980207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA511I050204Medicare PIN