Provider Demographics
NPI:1497061287
Name:MARTHA B BOONE M.D. LLC
Entity Type:Organization
Organization Name:MARTHA B BOONE M.D. LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARTHA
Authorized Official - Middle Name:B
Authorized Official - Last Name:BOONE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-705-8366
Mailing Address - Street 1:3400 OLD MILTON PARKWAY
Mailing Address - Street 2:SUITE A560
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30005
Mailing Address - Country:US
Mailing Address - Phone:404-705-8366
Mailing Address - Fax:404-705-8314
Practice Address - Street 1:3400 OLD MILTON PARKWAY
Practice Address - Street 2:SUITE A560
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30005
Practice Address - Country:US
Practice Address - Phone:404-705-8366
Practice Address - Fax:404-705-8314
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-31
Last Update Date:2015-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA042408174400000X
GA42408208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
042408OtherLICENSE
GAF07948Medicare UPIN
042408OtherLICENSE