Healthcare Provider Details

I. General information

NPI: 1497798854
Provider Name (Legal Business Name): BRADFORD BOOTSTAYLOR M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 10/28/2022
Certification Date: 10/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 W PEACHTREE ST NW SUITE 500
ATLANTA GA
30308-3607
US

IV. Provider business mailing address

285 BOULEVARD NE STE 345A
ATLANTA GA
30312-4205
US

V. Phone/Fax

Practice location:
  • Phone: 404-475-0816
  • Fax: 404-875-7102
Mailing address:
  • Phone: 404-618-6825
  • Fax: 404-480-3876

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number041733
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207VM0101X
TaxonomyMaternal & Fetal Medicine Physician
License Number041733
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: