Provider Demographics
NPI:1962483271
Name:BOOTHBY, FRED (CNP)
Entity type:Individual
Prefix:
First Name:FRED
Middle Name:
Last Name:BOOTHBY
Suffix:
Gender:M
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3285 122ND AVE
Mailing Address - Street 2:P.O. DRAWER 130
Mailing Address - City:ALLEGAN
Mailing Address - State:MI
Mailing Address - Zip Code:49010-9511
Mailing Address - Country:US
Mailing Address - Phone:269-673-6617
Mailing Address - Fax:269-673-2738
Practice Address - Street 1:3285 122ND AVE
Practice Address - Street 2:P.O. DRAWER 130
Practice Address - City:ALLEGAN
Practice Address - State:MI
Practice Address - Zip Code:49010-9511
Practice Address - Country:US
Practice Address - Phone:269-673-6617
Practice Address - Fax:269-673-2738
Is Sole Proprietor?:No
Enumeration Date:2005-11-14
Last Update Date:2008-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704142595363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4699274Medicaid
MI5008704740OtherBCBS
MI5008704740OtherBCBS
MI4699274Medicaid