Provider Demographics
NPI:1871828897
Name:BOOTHBY, MATTHEW R
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:R
Last Name:BOOTHBY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 GLYNCO PKWY STE 300
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:GA
Mailing Address - Zip Code:31525-7933
Mailing Address - Country:US
Mailing Address - Phone:912-262-6552
Mailing Address - Fax:912-262-6599
Practice Address - Street 1:1111 GLYNCO PKWY STE 300
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31525-7933
Practice Address - Country:US
Practice Address - Phone:912-262-6552
Practice Address - Fax:912-262-6599
Is Sole Proprietor?:No
Enumeration Date:2009-10-08
Last Update Date:2015-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA005660363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
202I975974Medicare Oscar/Certification