MEDICARE: DR. MARK ROBIN BOOTHBY M.D.

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	207RR0500X	Rheumatology Physician	MD0000024137	TN

General Provider Information

NPI Number	:	1336460054
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARK ROBIN BOOTHBY M.D.

Provider Business Mailing Address
First Line	:	2104 20TH AVE S
Second Line	:
City	:	NASHVILLE
State	:	TN
Zip	:	37212-4312
Country	:	US
Telephone Number	:	615-343-1699
Fax Number	:	615-343-7392

Provider Business Practice Location Address
First Line	:	DIV OF RHEUMATOLOGY VANDERBILT MEDICAL CTR
Second Line	:	T-3217 MEDICAL CENTER NORTH, 1161 21ST AVE S
City	:	NASHVILLE
State	:	TN
Zip	:	37232-0001
Country	:	US
Telephone Number	:	615-343-1699
Fax Number	:	615-343-7392

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

Provider Enumeration Date	:	06/16/2010
Last Update Date	:	06/16/2010

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