Provider Demographics
NPI:1407064165
Name:BOOTH, KEVIN R (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:R
Last Name:BOOTH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:2701 BLAIR MILL RD
Mailing Address - Street 2:STE 8
Mailing Address - City:WILLOW GROVE
Mailing Address - State:PA
Mailing Address - Zip Code:19090-1041
Mailing Address - Country:US
Mailing Address - Phone:215-886-7000
Mailing Address - Fax:
Practice Address - Street 1:2701 BLAIR MILL RD
Practice Address - Street 2:STE 8
Practice Address - City:WILLOW GROVE
Practice Address - State:PA
Practice Address - Zip Code:19090-1041
Practice Address - Country:US
Practice Address - Phone:215-886-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMD038228E2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAE67319Medicare UPIN