TENNESSEE VALLEY VASCULAR CONSULTANTS PC

Provider Demographics

• NPI: 1780613059
• Name: TENNESSEE VALLEY VASCULAR CONSULTANTS PC
• Entity type: Organization
• Organization Name: TENNESSEE VALLEY VASCULAR CONSULTANTS PC
• Authorized Official - Title/Position: PRESIDENT
• Authorized Official - First Name: FRED
• Authorized Official - Middle Name: S
• Authorized Official - Last Name: STUCKY
• Authorized Official - Suffix: III
• Authorized Official - Credentials: MD
• Authorized Official - Phone: 256-265-7480
• Mailing Address - Street 1: 420 LOWELL DR SE
• Mailing Address - Street 2: SUITE 500
• Mailing Address - City: HUNTSVILLE
• Mailing Address - State: AL
• Mailing Address - Zip Code: 35801-3754
• Mailing Address - Country: US
• Mailing Address - Phone: 256-265-7480
• Mailing Address - Fax: 256-265-7481
• Practice Address - Street 1: 420 LOWELL DR SE
• Practice Address - Street 2: SUITE 500
• Practice Address - City: HUNTSVILLE
• Practice Address - State: AL
• Practice Address - Zip Code: 35801-3754
• Practice Address - Country: US
• Practice Address - Phone: 256-265-7480
• Practice Address - Fax: 256-265-7481
• EIN: <UNAVAIL>
• Is Organization Subpart?: No
• Enumeration Date: 2006-06-30
• Last Update Date: 2008-06-06

Provider Licenses

State	License ID	Taxonomies
AL	00016783	2086S0129X
AL	00017567	2086S0129X
AL	0008023	2086S0129X

Provider Taxonomies

Primary?	Code	Type	Classification	Specialization	Group
Yes	2086S0129X	Allopathic & Osteopathic Physicians	Surgery	Vascular Surgery	Group - Single Specialty

Provider Identifiers

State	Identifier ID	ID Type	Issuer
AL	51514735STU	Other	BLUE CROSS BLUE SHIELD
AL	51514734JOH	Other	BLUE CROSS BLUE SHIELD
AL	P00000016	Other	MEDICARE RAILROAD
AL	051514735	Medicaid
	0005683727	Other	AETNA
AL	051514734	Medicaid
AL	P00000018	Other	MEDICARE RAILROAD
AL	051514736	Medicaid
AL	51514736LOW	Other	BLUE CROSS BLUE SHIELD
AL	P00000017	Other	MEDICARE RAILROAD
	0004070317	Other	AETNA
	0005999121	Other	AETNA
AL	051514734	Medicaid
AL	P00000017	Other	MEDICARE RAILROAD
	D45970	Medicare UPIN
AL	P00000018	Other	MEDICARE RAILROAD
	0005683727	Other	AETNA
AL	P00000016	Other	MEDICARE RAILROAD
AL	5735330001	Medicare NSC