Provider Demographics
NPI:1720292642
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:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:HENRY
Authorized Official - Last Name:TADLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
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
Mailing Address - Country:US
Mailing Address - Phone:702-474-0200
Mailing Address - Fax:702-474-7165
Practice Address - Street 1:6725 S. EASTERN AVE.
Practice Address - Street 2:SUITE 6
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119
Practice Address - Country:US
Practice Address - Phone:702-474-0200
Practice Address - Fax:702-946-5328
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-09
Last Update Date:2015-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV48411207LP2900X, 207LP2900X
NV8402207LP2900X
AZ26067207LP2900X, 207LP2900X
NVPA1256363AM0700X
NVAPN001241363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100502539Medicaid
AZZ35713Medicare PIN
NV100502539Medicaid
UT000058097Medicare ID - Type UnspecifiedGROUP