Provider Demographics
NPI:1669784252
Name:MODERN OBSTETRICS AND GYNECOLOGY OF NORTH ATLANTA PC
Entity type:Organization
Organization Name:MODERN OBSTETRICS AND GYNECOLOGY OF NORTH ATLANTA PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:INGRID
Authorized Official - Middle Name:VIVIAN
Authorized Official - Last Name:REYES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-446-2496
Mailing Address - Street 1:10692 MEDLOCK BRIDGE RD
Mailing Address - Street 2:SUITE 100A
Mailing Address - City:JOHNS CREEK
Mailing Address - State:GA
Mailing Address - Zip Code:30097-1890
Mailing Address - Country:US
Mailing Address - Phone:404-446-2496
Mailing Address - Fax:
Practice Address - Street 1:10692 MEDLOCK BRIDGE RD
Practice Address - Street 2:SUITE 100A
Practice Address - City:JOHNS CREEK
Practice Address - State:GA
Practice Address - Zip Code:30097-1890
Practice Address - Country:US
Practice Address - Phone:404-446-2496
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-12
Last Update Date:2016-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA064060207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1019123110002Medicaid
PA111359Medicare PIN