Provider Demographics
NPI:1376678854
Name:TENNESSEE VALLEY OB-GYN CLINIC PC
Entity type:Organization
Organization Name:TENNESSEE VALLEY OB-GYN CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:
Authorized Official - Last Name:CALLISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:256-265-6512
Mailing Address - Street 1:910 ADAMS ST STE 200
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35801-3759
Mailing Address - Country:US
Mailing Address - Phone:256-265-6512
Mailing Address - Fax:256-265-6727
Practice Address - Street 1:910 ADAMS ST SE STE 200
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35801-3759
Practice Address - Country:US
Practice Address - Phone:256-265-6512
Practice Address - Fax:256-265-6727
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-23
Last Update Date:2017-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL23915207V00000X, 207V00000X
AL25744207V00000X
AL1-094941363L00000X
AL1-058859363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL529910490Medicaid
ALI605Medicare PIN
AL0515-22996Medicaid
AL0515-22996Medicare ID - Type UnspecifiedDR. REIDY
AL0515-02692Medicaid
AL0515-02593Medicare ID - Type UnspecifiedDR. KAKANI
AL0515-02692Medicare ID - Type UnspecifiedDR. CALLISON
ALH44265Medicare UPIN
AL0515-02593Medicaid