MEDICARE: BOOTH DERMATOLOGY GROUP, PC

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	207N00000X	Dermatology Physician		IN

General Provider Information

NPI Number	:	1346220563
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BOOTH DERMATOLOGY GROUP, PC

Provider Business Mailing Address
First Line	:	12050 N MICHIGAN RD
Second Line	:
City	:	ZIONSVILLE
State	:	IN
Zip	:	46077-8782
Country	:	US
Telephone Number	:	317-848-2427
Fax Number	:	317-848-2434

Provider Business Practice Location Address
First Line	:	12050 N MICHIGAN RD
Second Line	:
City	:	ZIONSVILLE
State	:	IN
Zip	:	46077-8782
Country	:	US
Telephone Number	:	317-848-2427
Fax Number	:	317-848-2434

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. SALLY A BOOTH
Credential	:	MD
Telephone Number	:	317-848-2427

Provider Enumeration Date	:	01/23/2006
Last Update Date	:	06/15/2020

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