NPIMap

Organization Active NPI

Mobolaji Shalom Oyebanjo, Inc

Doing business as The Potter Behavioral Medicine Clinic

  • Psychiatry Physician
  • Villa Rica, GA
National Provider Identifier
1922280684
Registry record updated Oct 3, 2012
On this page

Key facts

NPPES NPI Registry
Primary specialty
Psychiatry PhysicianTaxonomy code 2084P0800X
Legal business name
MOBOLAJI SHALOM OYEBANJO, INC
Doing business as
The Potter Behavioral Medicine Clinic
Practice address
307 Old Stone Rd
Villa Rica, GA 30180-1214
Phone
(770) 459-8799
Fax
(770) 459-8919
NPI assigned
Dec 4, 2007
Last updated
Oct 3, 2012By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 3, 2012

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

Authorized official

Name
Mobolaji Oyebanjo, MD
Title
Provider
Phone
(770) 459-8799

Specialties & licenses 4

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207Q00000X
Psychiatry PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 2084P0800X Primary
Addiction Psychiatry PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 2084P0802X
Mental Health Clinic/Center (Including Community Mental Health Center) 261QM0801X

Addresses

Primary practice location

307 Old Stone Rd
Villa Rica, GA 30180-1214

Mailing address

307 Old Stone Rd
Villa Rica, GA 30180-1214
Phone (770) 459-8799

Other names 1

  • The Potter Behavioral Medicine Clinic Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20080428000562 GA Part B Supplier - Clinic/Group Practice 6204914401 Receives reassigned benefits from 10 practitioners
Practice locations: Villa Rica, GA; Stockbridge, GA; East Point, GA; Hiram, GA; Decatur, GA

National Provider Directory

National Provider Directory

Locations

110 Evans Mill Dr
Ste 501
Dallas, GA 30157
Phone (770) 459-8799

4150 Snapfinger Woods Dr
#2
Decatur, GA 30035
Phone (770) 459-8799

5604 Wendy Bagwell Pkwy
Ste 611
Hiram, GA 30141
Phone (770) 439-3070

307 Old Stone Rd
Villa Rica, GA 30180
Phone (770) 459-8799

514 W Bankhead Hwy
Ste 500
Villa Rica, GA 30180
Phone (770) 459-8799

Interoperability endpoints

  • FHIR API: https://fhir4.healow.com/fhir/r4/BCEGCD

Practitioners & affiliated clinicians

Practitioners 14

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 14

NPI Registry JSON

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

{
    "created_epoch": "1196726400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1349222400000",
    "number": "1922280684",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "307 OLD STONE RD",
            "city": "VILLA RICA",
            "state": "GA",
            "postal_code": "301801214",
            "telephone_number": "770-459-8799",
            "fax_number": "770-459-8919"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "307 OLD STONE RD",
            "city": "VILLA RICA",
            "state": "GA",
            "postal_code": "301801214",
            "telephone_number": "770-459-8799",
            "fax_number": "770-459-8919"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MOBOLAJI SHALOM OYEBANJO, INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-12-04",
        "last_updated": "2012-10-03",
        "status": "A",
        "authorized_official_last_name": "OYEBANJO",
        "authorized_official_first_name": "MOBOLAJI",
        "authorized_official_title_or_position": "PROVIDER",
        "authorized_official_telephone_number": "770-459-8799",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "2084P0800X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Psychiatry & Neurology, Psychiatry",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "2084P0802X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Psychiatry & Neurology, Addiction Psychiatry",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QM0801X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Mental Health (Including Community Mental Health Center)",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "The Potter Behavioral Medicine Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Villa Rica, GA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 3, 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.