Healthcare Provider Details

I. General information

NPI: 1497798615
Provider Name (Legal Business Name): THOMAS RAYFORD BLACKLEDGE JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 08/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 THIRD ST SW
MAGEE MS
39111
US

IV. Provider business mailing address

800 3RD ST SW PO BOX 748
MAGEE MS
39111-3951
US

V. Phone/Fax

Practice location:
  • Phone: 601-849-1918
  • Fax:
Mailing address:
  • Phone: 601-849-1918
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number14559
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: