Healthcare Provider Details

I. General information

NPI: 1134568967
Provider Name (Legal Business Name): GEORGE AUSTIN BOOTHE CRNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/14/2013
Last Update Date: 06/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4770 WOODMERE BLVD STE B
MONTGOMERY AL
36106-3084
US

IV. Provider business mailing address

4770 WOODMERE BLVD STE B
MONTGOMERY AL
36106-3084
US

V. Phone/Fax

Practice location:
  • Phone: 334-272-1050
  • Fax:
Mailing address:
  • Phone: 334-272-1050
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1-109113
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: