Healthcare Provider Details

I. General information

NPI: 1205481736
Provider Name (Legal Business Name): NORTHSIDE NAMA PROFESSIONAL SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/01/2019
Last Update Date: 08/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2545 LAWRENCEVILLE HWY STE 200
DECATUR GA
30033-3240
US

IV. Provider business mailing address

1000 JOHNSON FERRY ROAD, NE ATTN: JORGE HERNANDEZ
ATLANTA GA
30342
US

V. Phone/Fax

Practice location:
  • Phone: 770-934-7876
  • Fax:
Mailing address:
  • Phone: 404-851-6379
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. JORGE HERNANDEZ
Title or Position: CCO
Credential:
Phone: 404-851-6378