Provider Demographics
NPI:1669534210
Name:MY OBGYN PC
Entity type:Organization
Organization Name:MY OBGYN PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LETITIA
Authorized Official - Middle Name:D
Authorized Official - Last Name:ROYSTER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-996-1200
Mailing Address - Street 1:PO BOX 962380
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30296-6921
Mailing Address - Country:US
Mailing Address - Phone:770-996-1200
Mailing Address - Fax:770-907-2334
Practice Address - Street 1:81 UPPER RIVERDALE RD
Practice Address - Street 2:SUITE 210
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30274-2627
Practice Address - Country:US
Practice Address - Phone:770-996-1200
Practice Address - Fax:770-907-7492
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2012-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA044077174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA300020659AMedicaid