Provider Demographics
NPI:1275860256
Name:BOOTH, ASHLIE ALEXANDER (MD)
Entity Type:Individual
Prefix:
First Name:ASHLIE
Middle Name:ALEXANDER
Last Name:BOOTH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1208 E 38TH ST
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31404-3321
Mailing Address - Country:US
Mailing Address - Phone:912-604-9034
Mailing Address - Fax:
Practice Address - Street 1:1000 TOWNE CENTER BLVD STE 604A
Practice Address - Street 2:
Practice Address - City:POOLER
Practice Address - State:GA
Practice Address - Zip Code:31322-4052
Practice Address - Country:US
Practice Address - Phone:912-450-4450
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-11
Last Update Date:2019-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MST2903207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05903095Medicaid