Provider Demographics
NPI:1871878876
Name:MICHAEL H BOOTHBY, MD PA
Entity type:Organization
Organization Name:MICHAEL H BOOTHBY, MD PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:H
Authorized Official - Last Name:BOOTHBY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-529-1900
Mailing Address - Street 1:2901 ACME BRICK PLZ
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76109-4124
Mailing Address - Country:US
Mailing Address - Phone:817-529-1900
Mailing Address - Fax:817-529-1910
Practice Address - Street 1:2901 ACME BRICK PLZ
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76109-4124
Practice Address - Country:US
Practice Address - Phone:817-529-1900
Practice Address - Fax:817-529-1910
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-21
Last Update Date:2024-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX297334901Medicaid
TX1669419743OtherINDIVIDUAL NPI
TXM1030OtherLICENSE
TX182488001Medicaid
TXA0140043OtherDPS
TXA0140043OtherDPS
TXA0140043OtherDPS
TXBB9303657OtherDEA
8V9720OtherBCBS