Tennessee Valley Cardiovascular Center, P.C.

Contacts

Phone	+1 256-383-8066
Fax	2563838727

Authorized person

Name	TAMMY VARIE HADDOCK
Role	CREDENTIALS SPECIALIST
Phone	2567662118

Taxonomy

Taxonomy Code	207RC0000X - Cardiovascular Disease Physician
License Number	23786
State	AL
Is Primary	Yes

Other Provider Identifiers

Issuer	MEDICAID
Number	529202460
State	AL

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	1990-09-19
Business code	621111
Sponsor’s telephone number	2567662118
Plan sponsor’s DBA name	TENNESSEE VALLEY CARDIOVASCULAR CENTER, P.C.
Plan sponsor’s mailing address	541 W. COLLEGE ST, SUITE 1100, FLORENCE, AL, 35630
Plan sponsor’s address	541 W. COLLEGE ST, SUITE 1100, FLORENCE, AL, 35630

Plan administrator’s name and address

Administrator’s EIN	631069711
Plan administrator’s name	TENNESSEE VALLEY CARDIOVASCULAR CENTER, P.C.
Plan administrator’s address	541 W. COLLEGE ST, SUITE 1100, FLORENCE, AL, 35630
Administrator’s telephone number	2567662118

Number of participants as of the end of the plan year

Active participants	28
Retired or separated participants receiving benefits	6
Other retired or separated participants entitled to future benefits	2
Deceased participants whose beneficiaries are receiving or are entitled to receive benefits	0
Number of participants with account balances as of the end of the plan year	35
Number of participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	0

Signature of

Role	Plan administrator
Date	2010-03-30
Name of individual signing	JOHN REINKE
Valid signature	Filed with authorized/valid electronic signature