MEDICARE: CAROLYN M. BOOTH PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant		IL

General Provider Information

NPI Number	:	1033275631
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CAROLYN M. BOOTH PA

Provider Business Mailing Address
First Line	:	6000 BOND AVE
Second Line	:
City	:	EAST SAINT LOUIS
State	:	IL
Zip	:	62207-2328
Country	:	US
Telephone Number	:	618-332-2740
Fax Number	:	618-332-8755

Provider Business Practice Location Address
First Line	:	6000 BOND AVE
Second Line	:
City	:	EAST SAINT LOUIS
State	:	IL
Zip	:	62207-2328
Country	:	US
Telephone Number	:	618-332-2740
Fax Number	:	618-332-8755

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/28/2006
Last Update Date	:	07/08/2007

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