MEDICARE: NORTHSIDE PRIMARY CARE PROFESSIONAL SERVICES, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208D00000X	General Practice Physician		GA
2	261QU0200X	Urgent Care Clinic/Center		GA

General Provider Information

NPI Number	:	1215369715
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHSIDE PRIMARY CARE PROFESSIONAL SERVICES, LLC

Provider Business Mailing Address
First Line	:	1100 JOHNSON FERRY RD
Second Line	:	SUITE 780
City	:	ATLANTA
State	:	GA
Zip	:	30342-1709
Country	:	US
Telephone Number	:	404-851-6378
Fax Number	:

Provider Business Practice Location Address
First Line	:	81 NORTHSIDE DAWSON DRIVE
Second Line	:
City	:	DAWSONVILLE
State	:	GA
Zip	:	30534-7166
Country	:	US
Telephone Number	:	855-709-4535
Fax Number	:

Authorized Official
Title or Position	:	VP-ADMIN, CCO
Name	:	JORGE J. HERNANDEZ
Credential	:
Telephone Number	:	404-851-6378

Provider Enumeration Date	:	08/07/2013
Last Update Date	:	05/14/2026

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