MEDICARE: MARK W BOOKOUT M.D.

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	207Y00000X	Otolaryngology Physician	011511	TN
2	207Y00000X	Otolaryngology Physician	025947	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1356339063
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARK W BOOKOUT M.D.

Provider Business Mailing Address
First Line	:	6918 SHALLOWFORD RD
Second Line	:	SUITE 206
City	:	CHATTANOOGA
State	:	TN
Zip	:	37421-6784
Country	:	US
Telephone Number	:	423-855-2552
Fax Number	:	423-855-9041

Provider Business Practice Location Address
First Line	:	4151 RINGGOLD RD
Second Line	:
City	:	EAST RIDGE
State	:	TN
Zip	:	37412-2434
Country	:	US
Telephone Number	:	423-622-5165
Fax Number	:	423-622-5167

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/07/2005
Last Update Date	:	12/10/2012

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Directions to “ MARK W BOOKOUT M.D.” Practice Location

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