MEDICARE: NORTHSIDE WOMENS GROUP 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	207V00000X	Obstetrics & Gynecology Physician

General Provider Information

NPI Number	:	1245193358
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHSIDE WOMENS GROUP LLC

Provider Business Mailing Address
First Line	:	1000 JOHNSON FY RD NE
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30342-1606
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	460 NORTHSIDE CHEROKEE BLVD STE 360
Second Line	:
City	:	CANTON
State	:	GA
Zip	:	30115-8019
Country	:	US
Telephone Number	:	770-255-2550
Fax Number	:

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

Provider Enumeration Date	:	12/05/2025
Last Update Date	:	12/05/2025

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