MEDICARE: FRED J. RAHAIM, PH.D. P.A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	PY00002524	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1265475412	OTHER		NPI

General Provider Information

NPI Number	:	1972939767
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FRED J. RAHAIM, PH.D. P.A.

Provider Business Mailing Address
First Line	:	5635 CREST CREEK DR
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32258-5358
Country	:	US
Telephone Number	:	904-704-0851
Fax Number	:	904-880-0652

Provider Business Practice Location Address
First Line	:	5635 CREST CREEK DR
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32258-5358
Country	:	US
Telephone Number	:	904-704-0851
Fax Number	:	904-880-0652

Authorized Official
Title or Position	:	LICENSED PSYCHOLOGIST
Name	:	DR. FRED JOSEPH RAHAIM
Credential	:	PH.,D.
Telephone Number	:	904-704-0851

Provider Enumeration Date	:	09/24/2013
Last Update Date	:	09/24/2013

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