Basic Information
| Provider Information | |||||||||
| NPI: | 1225072598 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOOTH | ||||||||
| FirstName: | CAROL | ||||||||
| MiddleName: | WITCRAFT | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1875 DEMPSTER ST | ||||||||
| Address2: | SUITE 310 | ||||||||
| City: | PARK RIDGE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600681186 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8477237705 | ||||||||
| FaxNumber: | 8477238675 | ||||||||
| Practice Location | |||||||||
| Address1: | 1875 DEMPSTER ST | ||||||||
| Address2: | SUITE 310 | ||||||||
| City: | PARK RIDGE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600681186 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8477237705 | ||||||||
| FaxNumber: | 8477238675 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2006 | ||||||||
| LastUpdateDate: | 03/10/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207SG0201X | 036042710 | IL | Y | Allopathic & Osteopathic Physicians | Medical Genetics | Clinical Genetics (M.D.) |
ID Information
| ID | Type | State | Issuer | Description | 460002585 | 01 | RR MED PIN | OTHER | 036042710 | 05 | IL | MEDICAID | C19354 | 01 | RR MED GROUP | OTHER |