Healthcare Provider Details

I. General information

NPI: 1245193358
Provider Name (Legal Business Name): NORTHSIDE WOMENS GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2025
Last Update Date: 12/05/2025
Certification Date: 12/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

460 NORTHSIDE CHEROKEE BLVD STE 360
CANTON GA
30115-8019
US

IV. Provider business mailing address

1000 JOHNSON FY RD NE
ATLANTA GA
30342-1606
US

V. Phone/Fax

Practice location:
  • Phone: 770-255-2550
  • 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 ADMIN SVCS/CCO
Credential:
Phone: 404-851-6378