NPIMap

Organization Active NPI

My OBGYN PC

  • Specialist
  • Riverdale, GA
National Provider Identifier
1669534210
Registry record updated Nov 9, 2012
On this page

Key facts

NPPES NPI Registry
Primary specialty
SpecialistTaxonomy code 174400000X
License
044077 Issued in GA
Legal business name
MY OBGYN PC
Practice address
81 Upper Riverdale Rd
Suite 210
Riverdale, GA 30274-2627
Phone
(770) 996-1200
Fax
(770) 907-7492
NPI assigned
Dec 13, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Nov 9, 2012

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Letitia D Royster, M.D.NPI 1356425292
Title
Vice President
Phone
(770) 996-1200

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
SpecialistGroup: 193400000X SINGLE SPECIALTY GROUP 174400000X 044077 GA Primary

Addresses

Primary practice location

81 Upper Riverdale Rd
Suite 210
Riverdale, GA 30274-2627

Mailing address

PO Box 962380
Riverdale, GA 30296-6921
Phone (770) 996-1200

Other identifiers 1

IdentifierTypeStateIssuer
300020659AMedicaidGA

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in GA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20040528000396 GA Part B Supplier - Clinic/Group Practice 9335120997 Receives reassigned benefits from 3 practitioners
Practice locations: Riverdale, GA

National Provider Directory

National Provider Directory

Locations

335 Upper Riverdale Rd
Ste C13
Jonesboro, GA 30236
Phone (770) 996-1200

Practitioners & affiliated clinicians

Practitioners 15

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 15

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1165968000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1352419200000",
    "number": "1669534210",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 962380",
            "city": "RIVERDALE",
            "state": "GA",
            "postal_code": "302966921",
            "telephone_number": "770-996-1200",
            "fax_number": "770-907-2334"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "81 UPPER RIVERDALE RD",
            "address_2": "SUITE 210",
            "city": "RIVERDALE",
            "state": "GA",
            "postal_code": "302742627",
            "telephone_number": "770-996-1200",
            "fax_number": "770-907-7492"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MY OBGYN PC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-12-13",
        "last_updated": "2012-11-09",
        "status": "A",
        "authorized_official_last_name": "ROYSTER",
        "authorized_official_first_name": "LETITIA",
        "authorized_official_middle_name": "D",
        "authorized_official_title_or_position": "VICE PRESIDENT",
        "authorized_official_telephone_number": "770-996-1200",
        "authorized_official_credential": "M.D."
    },
    "taxonomies": [
        {
            "code": "174400000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Specialist",
            "state": "GA",
            "license": "044077",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "300020659A",
            "state": "GA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Riverdale, GA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 9, 2012; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.