Healthcare Provider Details

I. General information

NPI: 1508216680
Provider Name (Legal Business Name): RAYHAN A. TARIQ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2016
Last Update Date: 08/30/2021
Certification Date: 08/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1002 JEFFERSON STREET SUITE 300
LAUREL MS
39440-4306
US

IV. Provider business mailing address

PO BOX 247
LAUREL MS
39441-0247
US

V. Phone/Fax

Practice location:
  • Phone: 601-425-7500
  • Fax:
Mailing address:
  • Phone: 601-425-7550
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number11550462-1205
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMT211207
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number27726
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: