Provider Demographics
NPI:1942367164
Name:TADLOCK, RACHAEL F (MD)
Entity Type:Individual
Prefix:DR
First Name:RACHAEL
Middle Name:F
Last Name:TADLOCK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1721 MEDICAL PARK DR STE 101
Mailing Address - Street 2:
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39532-2105
Mailing Address - Country:US
Mailing Address - Phone:228-388-0062
Mailing Address - Fax:228-388-1701
Practice Address - Street 1:1721 MEDICAL PARK DR STE 101
Practice Address - Street 2:
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39532-2105
Practice Address - Country:US
Practice Address - Phone:228-388-0062
Practice Address - Fax:228-388-1701
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS17319207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00124506Medicaid
MSH23096Medicare UPIN