Healthcare Provider Details

I. General information

NPI: 1881667046
Provider Name (Legal Business Name): VANCE ANDRE' RAHAM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2006
Last Update Date: 04/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

335 ROSELANE ST NW STE 203
MARIETTA GA
30060-7902
US

IV. Provider business mailing address

335 ROSELANE ST NW STE 203
MARIETTA GA
30060-7902
US

V. Phone/Fax

Practice location:
  • Phone: 678-882-0878
  • Fax: 678-224-8183
Mailing address:
  • Phone: 678-882-0878
  • Fax: 678-224-8183

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number01045645A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01045645A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: