Basic Information
| Provider Information | |||||||||
| NPI: | 1962483271 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOOTHBY | ||||||||
| FirstName: | FRED | ||||||||
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| Credential: | CNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3285 122ND AVE | ||||||||
| Address2: | P.O. DRAWER 130 | ||||||||
| City: | ALLEGAN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490109511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2696736617 | ||||||||
| FaxNumber: | 2696732738 | ||||||||
| Practice Location | |||||||||
| Address1: | 3285 122ND AVE | ||||||||
| Address2: | P.O. DRAWER 130 | ||||||||
| City: | ALLEGAN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490109511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2696736617 | ||||||||
| FaxNumber: | 2696732738 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2005 | ||||||||
| LastUpdateDate: | 01/18/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 4704142595 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 4699274 | 05 | MI | MEDICAID | 5008704740 | 01 | MI | BCBS | OTHER |