MEDICARE: SHADES VALLEY DERMATOLOGY, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207N00000X	Dermatology Physician	23903	AL

General Provider Information

NPI Number	:	1831548668
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SHADES VALLEY DERMATOLOGY, LLC

Provider Business Mailing Address
First Line	:	1600 5TH AVE S
Second Line	:
City	:	JASPER
State	:	AL
Zip	:	35501-4658
Country	:	US
Telephone Number	:	205-578-1799
Fax Number	:	205-512-1111

Provider Business Practice Location Address
First Line	:	1600 5TH AVE S
Second Line	:
City	:	JASPER
State	:	AL
Zip	:	35501-4658
Country	:	US
Telephone Number	:	205-578-1799
Fax Number	:	205-512-1111

Authorized Official
Title or Position	:	MD
Name	:	KATHERINE FLANAGAN
Credential	:
Telephone Number	:	205-578-1799

Provider Enumeration Date	:	06/13/2016
Last Update Date	:	02/04/2026

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