Provider Demographics
NPI:1225324791
Name:PTACEK, TYLER ANTHONY (MD)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:ANTHONY
Last Name:PTACEK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6020
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57709-6020
Mailing Address - Country:US
Mailing Address - Phone:605-342-3280
Mailing Address - Fax:605-791-0192
Practice Address - Street 1:101 E MINNESOTA ST STE 200
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-7758
Practice Address - Country:US
Practice Address - Phone:605-342-3280
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-23
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE6652207L00000X
KS7731207Q00000X
MO2016019592208VP0014X
SD12138208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine