Provider Demographics
NPI:1710980776
Name:RAUCH, SAMUEL D JR (MD)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:D
Last Name:RAUCH
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:399 PENINSULA RD
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30506-1705
Mailing Address - Country:US
Mailing Address - Phone:770-536-8585
Mailing Address - Fax:770-297-5023
Practice Address - Street 1:1240 JESSE JEWELL PKWY SE
Practice Address - Street 2:STE 500
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-3861
Practice Address - Country:US
Practice Address - Phone:678-350-3636
Practice Address - Fax:770-297-5023
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA11452174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00086039AMedicaid
D40936Medicare UPIN