Healthcare Provider Details

I. General information

NPI: 1942828603
Provider Name (Legal Business Name): THOMAS C BOOTH II
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/09/2020
Last Update Date: 07/09/2020
Certification Date: 07/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3942 DAVIS STUART RD STE 3
RONCEVERTE WV
24970-0269
US

IV. Provider business mailing address

3942 DAVIS STUART RD STE 3
RONCEVERTE WV
24970-0269
US

V. Phone/Fax

Practice location:
  • Phone: 304-647-3987
  • Fax: 304-647-3990
Mailing address:
  • Phone: 304-647-3987
  • Fax: 304-647-3990

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberPT004290
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: