Provider Demographics
NPI:1346220563
Name:BOOTH DERMATOLOGY GROUP, PC
Entity type:Organization
Organization Name:BOOTH DERMATOLOGY GROUP, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SALLY
Authorized Official - Middle Name:A
Authorized Official - Last Name:BOOTH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:317-848-2427
Mailing Address - Street 1:12050 N MICHIGAN RD
Mailing Address - Street 2:
Mailing Address - City:ZIONSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46077-8782
Mailing Address - Country:US
Mailing Address - Phone:317-848-2427
Mailing Address - Fax:317-848-2434
Practice Address - Street 1:12050 N MICHIGAN RD
Practice Address - Street 2:
Practice Address - City:ZIONSVILLE
Practice Address - State:IN
Practice Address - Zip Code:46077-8782
Practice Address - Country:US
Practice Address - Phone:317-848-2427
Practice Address - Fax:317-848-2434
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-23
Last Update Date:2020-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN232350Medicare PIN