Provider Demographics
NPI:1881667046
Name:RAHAM, VANCE ANDRE' (MD)
Entity Type:Individual
Prefix:DR
First Name:VANCE
Middle Name:ANDRE'
Last Name:RAHAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:335 ROSELANE ST NW STE 203
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-7902
Mailing Address - Country:US
Mailing Address - Phone:678-882-0878
Mailing Address - Fax:678-224-8183
Practice Address - Street 1:335 ROSELANE ST NW STE 203
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-7902
Practice Address - Country:US
Practice Address - Phone:678-882-0878
Practice Address - Fax:678-224-8183
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2017-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01045645A207QA0401X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200111860AMedicaid
IN200111860AMedicaid