Healthcare Provider Details

I. General information

NPI: 1487974192
Provider Name (Legal Business Name): RALPH BROOKS VANCE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2010
Last Update Date: 01/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2510 LAKELAND DR
FLOWOOD MS
39232-9513
US

IV. Provider business mailing address

2510 LAKELAND DR
FLOWOOD MS
39232-9513
US

V. Phone/Fax

Practice location:
  • Phone: 313-916-2393
  • Fax:
Mailing address:
  • Phone: 601-355-1234
  • Fax: 601-352-4882

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number24918
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: