Letty Revell Peterson, M.D.

Primary specialty

Dermatology PhysicianTaxonomy code 207N00000X

License

058913 Issued in GA

Practice address

305 First St. West
Vidalia, GA 30474-7201

Phone

(912) 538-9080

NPI assigned

Mar 20, 2007

Last updated

Oct 22, 2012By the provider in NPPES

Sex

Female

Sole proprietor

Yes

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

Specialties & licenses 4

Addresses

Other identifiers 1

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: Yes
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Specialty

Dermatology

Education

Medical College of Georgia School of Medicine, 2007

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Group practices

Peterson Dermatology, P.C.Group PAC ID 7113018334, 4 clinicians

Practice addresses (Care Compare)

Hospital & facility affiliations

• Memorial Health Meadows Hospital Hospital, Vidalia, GA, CCN 110128

Merit-based Incentive Payment System (MIPS)

Final score

77.65 of 100Reported as group

Quality

55.3

Improvement activities

40

Procedures performed for Medicare patients

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Medicine

State licenses

Practice roles

Locations

Interoperability endpoints

• FHIR API: https://fhir.nextgen.com/nge/prod/fhir-api-r4/fhir/r4/

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• Peterson Dermatology, P.C.

  • Dermatology Physician
  • Vidalia, GA
  • NPI 1932300886
  Medicare reassignment Care Compare group NPD Authorized official

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

• Vidalia Health Services, LLC

  • General Acute Care Hospital
  • Vidalia, GA
  • NPI 1790376564
  Care Compare affiliation

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

{
    "created_epoch": "1174348800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1350864000000",
    "number": "1760507974",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "305 FIRST ST. WEST",
            "city": "VIDALIA",
            "state": "GA",
            "postal_code": "304747201",
            "telephone_number": "912-538-9080"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "305 FIRST ST. WEST",
            "city": "VIDALIA",
            "state": "GA",
            "postal_code": "304747201",
            "telephone_number": "912-538-9080"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "PETERSON",
        "first_name": "LETTY",
        "middle_name": "REVELL",
        "name_prefix": "Dr.",
        "credential": "M.D.",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2007-03-20",
        "last_updated": "2012-10-22",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207N00000X",
            "taxonomy_group": "",
            "desc": "Dermatology",
            "state": "GA",
            "license": "058913",
            "primary": true
        },
        {
            "code": "207ND0101X",
            "taxonomy_group": "",
            "desc": "Dermatology, MOHS-Micrographic Surgery",
            "state": "GA",
            "license": "058913",
            "primary": false
        },
        {
            "code": "207NP0225X",
            "taxonomy_group": "",
            "desc": "Dermatology, Pediatric Dermatology",
            "state": "GA",
            "license": "058913",
            "primary": false
        },
        {
            "code": "207NS0135X",
            "taxonomy_group": "",
            "desc": "Dermatology, Procedural Dermatology",
            "state": "GA",
            "license": "058913",
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "551383524A",
            "state": "GA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• James R Payne, PA C
• Barbara T Peacock, FNP
• Brendan Darby Pearsall, PHARMD
• John Peery, RPH
• Peterson Dermatology, P.C.
• Phillips Drugs, Inc (Phillips Pharmacy)
• Phillips Drugs, Inc (Phillips Pharmacy (LTC))
• Amanda Shea Phillips, FNP
• Andrea Phillips
• Annilyne Michele Phillips, RPH

• Dermatology Physician in Vidalia, GA
• Providers in Vidalia, GA by specialty
• Dermatology Physician in Georgia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 22, 2012; 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.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.