Healthcare Provider Details

I. General information

NPI: 1942183421
Provider Name (Legal Business Name): NORTHSIDE WOMENS GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2025
Last Update Date: 08/22/2025
Certification Date: 08/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

980 JOHNSON FY RD NE STE 620
ATLANTA GA
30342-1608
US

IV. Provider business mailing address

1000 JOHNSON FY RD NE
ATLANTA GA
30342-1606
US

V. Phone/Fax

Practice location:
  • Phone: 404-255-2057
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State

VIII. Authorized Official

Name: JORGE J. HERNANDEZ
Title or Position: VP AMIN SVCS/CCO
Credential:
Phone: 404-851-6378