Active NPI
Myra Shivers
- Periodontics
- Fayetteville, GA
National Provider Identifier
1235355017
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Periodontics
- License
- 9975
- Practice address
- 118 N Park Dr
Fayetteville, GA 30214-1645 - Phone
- (770) 460-6765
- Fax
- (770) 460-5598
- NPI assigned
- Apr 18, 2007
- Sex
- Female
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Periodontics | 1223P0300X | 9975 | GA | Primary |
Addresses
Primary practice location
118 N Park Dr
Fayetteville, GA 30214-1645
Mailing address
118 N Park Dr
Fayetteville, GA 30214-1645
Phone (770) 460-6765
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in GA
- Eligible to order & refer
- Part B services: Yes
- Medical equipment: Yes
- Home health: Yes
- Power mobility devices: No
- Hospice: Yes
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20150713003068 | GA | Order and Referring Only - Dentist | 4587977038 |
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 9975 | GA | MD | Periodontist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1176854400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1183852800000",
"number": "1235355017",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "118 N PARK DR",
"city": "FAYETTEVILLE",
"state": "GA",
"postal_code": "302141645",
"telephone_number": "770-460-6765",
"fax_number": "770-460-5598"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "118 N PARK DR",
"city": "FAYETTEVILLE",
"state": "GA",
"postal_code": "302141645",
"telephone_number": "770-460-6765",
"fax_number": "770-460-5598"
}
],
"practiceLocations": [],
"basic": {
"last_name": "SHIVERS",
"first_name": "MYRA",
"name_prefix": "Dr.",
"sole_proprietor": "YES",
"sex": "F",
"enumeration_date": "2007-04-18",
"last_updated": "2007-07-08",
"status": "A"
},
"taxonomies": [
{
"code": "1223P0300X",
"taxonomy_group": "",
"desc": "Dentist, Periodontics",
"state": "GA",
"license": "9975",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Fayetteville, GA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.