Healthcare Provider Details

I. General information

NPI: 1609837350
Provider Name (Legal Business Name): MICHAEL E TADLOCK CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2006
Last Update Date: 12/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

916 4TH AVE. SW
PIPESTONE MN
56164
US

IV. Provider business mailing address

916 4TH AVE. SW
PIPESTONE MN
56164
US

V. Phone/Fax

Practice location:
  • Phone: 507-825-5811
  • Fax: 563-556-8334
Mailing address:
  • Phone: 507-825-5811
  • Fax: 563-556-8334

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberD103531
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number223779-0
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: