Provider Demographics
NPI:1376861757
Name:THOMAS R. BLACKLEDGE, JR., MD, PA
Entity Type:Organization
Organization Name:THOMAS R. BLACKLEDGE, JR., MD, PA
Other - Org Name:MEDICAL CENTER OF MAGEE
Other - Org Type:Other Name
Authorized Official - Title/Position:MD/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:R
Authorized Official - Last Name:BLACKLEDGE
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:601-849-1918
Mailing Address - Street 1:PO BOX 748
Mailing Address - Street 2:
Mailing Address - City:MAGEE
Mailing Address - State:MS
Mailing Address - Zip Code:39111-0748
Mailing Address - Country:US
Mailing Address - Phone:601-849-1918
Mailing Address - Fax:601-849-1908
Practice Address - Street 1:800 3RD ST SW
Practice Address - Street 2:
Practice Address - City:MAGEE
Practice Address - State:MS
Practice Address - Zip Code:39111-3951
Practice Address - Country:US
Practice Address - Phone:601-849-1918
Practice Address - Fax:601-849-1908
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-11
Last Update Date:2010-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS14559207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00115523Medicaid
MS080003399Medicare PIN
MS00115523Medicaid