NPIMap

Organization Active NPI

Modern Obstetrics and Gynecology of North Atlanta PC

  • Obstetrics & Gynecology Physician
  • Johns Creek, GA
National Provider Identifier
1669784252
Registry record updated Sep 23, 2016
On this page

Key facts

NPPES NPI Registry
Primary specialty
Obstetrics & Gynecology PhysicianTaxonomy code 207V00000X
License
064060 Issued in GA
Legal business name
MODERN OBSTETRICS AND GYNECOLOGY OF NORTH ATLANTA PC
Practice address
10692 Medlock Bridge Rd
Suite 100a
Johns Creek, GA 30097-1890
Phone
(404) 446-2496
NPI assigned
Jul 12, 2010
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Sep 23, 2016

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

Authorized official

Name
Ingrid Vivian Reyes, M.D.
Title
Secretary
Phone
(404) 446-2496

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Obstetrics & Gynecology PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 207V00000X 064060 GA Primary

Addresses

Primary practice location

10692 Medlock Bridge Rd
Suite 100a
Johns Creek, GA 30097-1890

Mailing address

10692 Medlock Bridge Rd
Suite 100a
Johns Creek, GA 30097-1890
Phone (404) 446-2496

Other identifiers 1

IdentifierTypeStateIssuer
1019123110002MedicaidPA

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20101111000348 GA Part B Supplier - Clinic/Group Practice 1557556966 Receives reassigned benefits from 1 practitioner
Practice locations: Johns Creek, GA

National Provider Directory

National Provider Directory

Locations

2710 Old Milton Pkwy
Ste 110
Alpharetta, GA 30009

1800 Northside Forsyth Dr
Ste 360
Cumming, GA 30041
Phone (470) 325-1280

2000 Howard Farm Dr
Ste 330
Cumming, GA 30041
Phone (404) 446-2496

10692 Medlock Bridge Rd
Ste 100A
Johns Creek, GA 30097
Phone (404) 446-2492

6335 Hospital Pkwy
Ste 204
Johns Creek, GA 30097
Phone (404) 446-2496

10692 Medlock Bridge Rd
Ste 100B
Johns Creek, GA 30097

10692 Medlock Bridge Rd
Johns Creek, GA 30097
Phone (404) 446-2492

6300 Hospital Pkwy
Ste 125
Johns Creek, GA 30097
Phone (404) 446-2496

Practitioners & affiliated clinicians

Practitioners 22

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

View all 22

NPI Registry JSON

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

{
    "created_epoch": "1278892800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1474588800000",
    "number": "1669784252",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "10692 MEDLOCK BRIDGE RD",
            "address_2": "SUITE 100A",
            "city": "JOHNS CREEK",
            "state": "GA",
            "postal_code": "300971890",
            "telephone_number": "404-446-2496"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "10692 MEDLOCK BRIDGE RD",
            "address_2": "SUITE 100A",
            "city": "JOHNS CREEK",
            "state": "GA",
            "postal_code": "300971890",
            "telephone_number": "404-446-2496"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MODERN OBSTETRICS AND GYNECOLOGY OF NORTH ATLANTA PC",
        "organizational_subpart": "NO",
        "enumeration_date": "2010-07-12",
        "last_updated": "2016-09-23",
        "status": "A",
        "authorized_official_last_name": "REYES",
        "authorized_official_first_name": "INGRID",
        "authorized_official_middle_name": "VIVIAN",
        "authorized_official_title_or_position": "SECRETARY",
        "authorized_official_telephone_number": "404-446-2496",
        "authorized_official_credential": "M.D."
    },
    "taxonomies": [
        {
            "code": "207V00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Obstetrics & Gynecology",
            "state": "GA",
            "license": "064060",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1019123110002",
            "state": "PA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Johns Creek, GA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 23, 2016; 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.