Provider Demographics
NPI:1659448975
Name:BOOTH MEDICAL CENTER PC
Entity Type:Organization
Organization Name:BOOTH MEDICAL CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:N
Authorized Official - Last Name:BOOTH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:260-463-4896
Mailing Address - Street 1:2600 N DETROIT ST
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:IN
Mailing Address - Zip Code:46761-1154
Mailing Address - Country:US
Mailing Address - Phone:260-463-4896
Mailing Address - Fax:260-463-5242
Practice Address - Street 1:2600 N DETROIT ST
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:IN
Practice Address - Zip Code:46761-1154
Practice Address - Country:US
Practice Address - Phone:260-463-4896
Practice Address - Fax:260-463-5242
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-30
Last Update Date:2010-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01041550A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100468460Medicaid
INF32948Medicare UPIN
IN100468460Medicaid