Healthcare Provider Details

I. General information

NPI: 1518922863
Provider Name (Legal Business Name): MARK A BOOTH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2006
Last Update Date: 12/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 S HILLSDALE ST
HOMER MI
49245-1248
US

IV. Provider business mailing address

420 S HILLSDALE ST
HOMER MI
49245-1248
US

V. Phone/Fax

Practice location:
  • Phone: 517-568-4481
  • Fax: 517-568-3720
Mailing address:
  • Phone: 517-568-4481
  • Fax: 517-568-3720

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301043850
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: