Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207Q00000X | Family Doctor | 01045645A | IN |
Y | 207QA0401X | Family Doctor - Addiction Medicine | 01045645A | IN |
NPI | 1881667046 |
---|---|
Provider Name | Dr. Vance Andre' Raham |
First Address | Marietta, GA 30060-7902 |
Second Address | Marietta, GA 30060-7902 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 08/02/2006 |
Last Update Date | 14/04/2017 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
200111860A | (05) | IN |