Provider Demographics
NPI:1497798615
Name:BLACKLEDGE, THOMAS RAYFORD JR (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:RAYFORD
Last Name:BLACKLEDGE
Suffix:JR
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 1:800 3RD ST SW
Mailing Address - Street 2:PO BOX 748
Mailing Address - City:MAGEE
Mailing Address - State:MS
Mailing Address - Zip Code:39111-3951
Mailing Address - Country:US
Mailing Address - Phone:601-849-1918
Mailing Address - Fax:
Practice Address - Street 1:800 THIRD ST SW
Practice Address - Street 2:
Practice Address - City:MAGEE
Practice Address - State:MS
Practice Address - Zip Code:39111
Practice Address - Country:US
Practice Address - Phone:601-849-1918
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-14
Last Update Date:2013-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS14559207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00115523Medicaid
MS00115523Medicaid
MS080003399Medicare ID - Type Unspecified