Provider Demographics
NPI:1225182272
Name:CONNERSVILLE OBGYN INC
Entity Type:Organization
Organization Name:CONNERSVILLE OBGYN INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:VANCE
Authorized Official - Middle Name:ANDRE'
Authorized Official - Last Name:RAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:765-825-0811
Mailing Address - Street 1:1619 N GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:CONNERSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47331-2230
Mailing Address - Country:US
Mailing Address - Phone:765-825-0811
Mailing Address - Fax:765-827-5278
Practice Address - Street 1:1619 N GRAND AVE
Practice Address - Street 2:
Practice Address - City:CONNERSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47331-2230
Practice Address - Country:US
Practice Address - Phone:765-825-0811
Practice Address - Fax:765-827-5278
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01045645207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN231580Medicare ID - Type Unspecified
ING39275Medicare UPIN