Provider Demographics
NPI:1508813692
Name:BOOTH, RAYMOND (CRNA)
Entity type:Individual
Prefix:
First Name:RAYMOND
Middle Name:
Last Name:BOOTH
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1125
Mailing Address - Street 2:
Mailing Address - City:MARYLAND HEIGHTS
Mailing Address - State:MO
Mailing Address - Zip Code:63043-0125
Mailing Address - Country:US
Mailing Address - Phone:888-731-1036
Mailing Address - Fax:423-892-5838
Practice Address - Street 1:11133 DUNN RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63136-6119
Practice Address - Country:US
Practice Address - Phone:314-923-4640
Practice Address - Fax:314-653-4131
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2008-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO081391367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO918546110Medicaid
MO203133OtherBCBS MO
MOP00273601OtherRR MEDICARE
MO203133OtherBCBS MO
MO918546110Medicaid
IL$$$$$$$$$001Medicaid