MEDICARE: JAMES RICHARDSON BOONE PH 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	103G00000X	Clinical Neuropsychologist	PY04361	FL
2	103T00000X	Psychologist	PY04361	FL

General Provider Information

NPI Number	:	1912114356
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAMES RICHARDSON BOONE PH D

Provider Business Mailing Address
First Line	:	2625 KEYSTONE RD
Second Line	:	SUITE A-3
City	:	TARPON SPRINGS
State	:	FL
Zip	:	34688-7436
Country	:	US
Telephone Number	:	727-944-4600
Fax Number	:	727-945-9800

Provider Business Practice Location Address
First Line	:	2625 KEYSTONE RD
Second Line	:	SUITE A-3
City	:	TARPON SPRINGS
State	:	FL
Zip	:	34688-7436
Country	:	US
Telephone Number	:	727-944-4600
Fax Number	:	727-945-9800

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

Provider Enumeration Date	:	05/16/2007
Last Update Date	:	12/14/2007

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