Provider Demographics
NPI:1174892780
Name:TENNESSEE VALLEY INTERNAL MEDICINE, PC
Entity type:Organization
Organization Name:TENNESSEE VALLEY INTERNAL MEDICINE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:A
Authorized Official - Last Name:PATELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:256-509-4010
Mailing Address - Street 1:3809 SULLIVAN ST
Mailing Address - Street 2:SUITE 7
Mailing Address - City:MADISON
Mailing Address - State:AL
Mailing Address - Zip Code:35758-2372
Mailing Address - Country:US
Mailing Address - Phone:256-428-1096
Mailing Address - Fax:256-428-1097
Practice Address - Street 1:3809 SULLIVAN ST
Practice Address - Street 2:SUITE 7
Practice Address - City:MADISON
Practice Address - State:AL
Practice Address - Zip Code:35758-2372
Practice Address - Country:US
Practice Address - Phone:256-428-1096
Practice Address - Fax:256-428-1097
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-28
Last Update Date:2012-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL136258Medicaid
AL136258Medicaid