MEDICARE: BERTA E 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	005897	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	005897	OTHER	GA	GEORGIA MEDICAL LICENSE

General Provider Information

NPI Number	:	1609183805
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BERTA E BOOTH PA

Provider Business Mailing Address
First Line	:	119 AMBULANCE DR 202
Second Line	:
City	:	CARROLLTON
State	:	GA
Zip	:	30117-3857
Country	:	US
Telephone Number	:	770-838-8710
Fax Number	:

Provider Business Practice Location Address
First Line	:	6572 RIVER PARK DR STE 101
Second Line	:
City	:	RIVERDALE
State	:	GA
Zip	:	30274-2214
Country	:	US
Telephone Number	:	770-996-6699
Fax Number	:	770-692-2669

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

Provider Enumeration Date	:	09/09/2010
Last Update Date	:	11/23/2015

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Directions to “ BERTA E BOOTH PA” Practice Location

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