Basic Information
| Provider Information | |||||||||
| NPI: | 1154594976 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOOTH | ||||||||
| FirstName: | CASSIE | ||||||||
| MiddleName: | LEE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 505164 | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631505164 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4178294620 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1235 E CHEROKEE ST | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658042203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4178202961 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2008 | ||||||||
| LastUpdateDate: | 06/16/2016 | ||||||||
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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 | 207ZP0105X | 106898 | MN | N | Allopathic & Osteopathic Physicians | Pathology | Clinical Pathology/Laboratory Medicine | 207ZP0105X | 56816 | MN | N | Allopathic & Osteopathic Physicians | Pathology | Clinical Pathology/Laboratory Medicine | 207ZP0102X | 2016008383 | MO | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | PENDING | 05 | OK | MEDICAID | PENDING | 05 | MO | MEDICAID | PENDING | 05 | AR | MEDICAID |