Healthcare Provider Details

I. General information

NPI: 1942461504
Provider Name (Legal Business Name): JACQUES C THAM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2008
Last Update Date: 08/05/2026
Certification Date: 08/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 N BROAD ST NE STE 140
ROME GA
30161-5202
US

IV. Provider business mailing address

901 N BROAD ST NE STE 140
ROME GA
30161-5202
US

V. Phone/Fax

Practice location:
  • Phone: 706-291-2661
  • Fax: 706-784-4375
Mailing address:
  • Phone: 706-291-2661
  • Fax: 706-784-4375

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number51388020
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number100115
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: