# BOOTH MEDICAL CENTER PC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1659448975
- **Authorized official:** LISA N BOOTH MD (PHYSICIAN OWNER)
- **Authorized official phone:** (260) 463-4896

## Contact information

- **Practice address:** 2600 N DETROIT ST, LAGRANGE, IN 46761-1154
- **Practice address phone:** (260) 463-4896
- **Practice address fax:** (260) 463-5242
- **Mailing address:** 2600 N DETROIT ST, LAGRANGE, IN 46761-1154
- **Mailing address phone:** (260) 463-4896
- **Mailing address fax:** (260) 463-5242

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207Q00000X | Family Medicine Physician | 01041550A | IN | Yes |

## Other

- **Enumeration date:** 11/30/2006
- **Last updated:** 07/20/2010

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 100468460 | — | IN |