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General NPI Number Information
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NPI Number | 1871828897
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Entity Type | Individual
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Provider Name | MR. MATTHEW R BOOTHBY
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Gender | Male
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Dates
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Enumeration Date | 10/08/2009
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Last Update Date | 05/01/2015
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Provider Practice Location Address
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Address Line | 1111 GLYNCO PKWY STE 300
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City | BRUNSWICK
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State | GA
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Zip | 31525-7933
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Country | US
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Telephone | 912-262-6552
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Fax | 912-262-6599
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Provider Business Mailing Address
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Address Line | 1111 GLYNCO PKWY STE 300
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City | BRUNSWICK
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State | GA
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Zip | 31525-7933
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Country | US
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Telephone | 912-262-6552
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Fax | 912-262-6599
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number | 005660
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License Number State | GA
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