Provider Demographics
NPI:1699715086
Name:BOOTHWYN MEDICAL ASSOCIATES P.C.
Entity type:Organization
Organization Name:BOOTHWYN MEDICAL ASSOCIATES P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RODNEY
Authorized Official - Middle Name:M
Authorized Official - Last Name:ELKIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:610-459-3722
Mailing Address - Street 1:1440 CONCHESTER HWY
Mailing Address - Street 2:SUITE 5A
Mailing Address - City:BOOTHWYN
Mailing Address - State:PA
Mailing Address - Zip Code:19061-2124
Mailing Address - Country:US
Mailing Address - Phone:610-459-3722
Mailing Address - Fax:610-459-4730
Practice Address - Street 1:1440 CONCHESTER HWY
Practice Address - Street 2:SUITE 5A
Practice Address - City:BOOTHWYN
Practice Address - State:PA
Practice Address - Zip Code:19061-2124
Practice Address - Country:US
Practice Address - Phone:610-459-3722
Practice Address - Fax:610-459-4730
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-07
Last Update Date:2011-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD038926L207QA0505X
PAMD030635E207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0012788500001Medicaid
PA0012788500001Medicaid