CHARLES H. TADLOCK, M.D. LTD.

Provider Demographics

• NPI: 1548422876
• Name: CHARLES H. TADLOCK, M.D. LTD.
• Entity Type: Organization
• Organization Name: CHARLES H. TADLOCK, M.D. LTD.
• Other - Org Name: CENTER FOR PAIN MANAGEMENT
• Other - Org Type: Doing Business As
• Authorized Official - Title/Position: ADMINISTRATOR
• Authorized Official - Prefix: MRS
• Authorized Official - First Name: TAMMY
• Authorized Official - Middle Name: R
• Authorized Official - Last Name: SHAFFER
• Authorized Official - Phone: 702-474-0200
• Mailing Address - Street 1: 6725 S EASTERN AVE
• Mailing Address - Street 2: SUITE 6
• Mailing Address - City: LAS VEGAS
• Mailing Address - State: NV
• Mailing Address - Zip Code: 89119-3916
• Mailing Address - Country: US
• Mailing Address - Phone: 702-474-0200
• Mailing Address - Fax: 702-946-5328
• Practice Address - Street 1: 1912 MIAMI AVE
• Practice Address - City: KINGMAN
• Practice Address - State: AZ
• Practice Address - Zip Code: 86401-4127
• Practice Address - Country: US
• Practice Address - Phone: 702-474-0200
• Practice Address - Fax: 702-946-5328
• EIN: <UNAVAIL>
• Is Organization Subpart?: No
• Enumeration Date: 2008-06-27
• Last Update Date: 2014-02-18

Provider Licenses

State	License ID	Taxonomies
AZ	26067	207LP2900X, 207LP2900X
AZ	4873	363AM0700X
AZ	AP4247	363LF0000X
AZ	30928	207LP2900X
AZ	3835	363AM0700X
AZ	3404	363AM0700X

Provider Taxonomies

Primary?	Code	Type	Classification	Specialization	Group
Yes	207LP2900X	Allopathic & Osteopathic Physicians	Anesthesiology	Pain Medicine	Group - Single Specialty
No	363AM0700X	Physician Assistants & Advanced Practice Nursing Providers	Physician Assistant	Medical	Group - Single Specialty
No	363LF0000X	Physician Assistants & Advanced Practice Nursing Providers	Nurse Practitioner	Family	Group - Single Specialty

Provider Identifiers

State	Identifier ID	ID Type	Issuer
AZ	35714	Other	MEDICARE INDIVIDUAL PIN (TADLOCK)
AZ	Z149395	Other	MEDICARE PIN JULIE BROWN, FNP
AZ	069618	Medicaid
AZ	Z146133	Other	MEDICARE PIN GERALD JONES, PA-C
AZ	720000127	Other	RR MEDICARE
AZ	Z149395	Other	MEDICARE PIN JULIE BROWN, FNP
AZ	069618	Medicaid
AZ	35713	Medicare PIN
AZ	35714	Other	MEDICARE INDIVIDUAL PIN (TADLOCK)