Healthcare Provider Details

I. General information

NPI: 1679136824
Provider Name (Legal Business Name): GWINNETT SURGICAL SPECIALISTS PROFESSIONAL SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/15/2019
Last Update Date: 06/02/2025
Certification Date: 06/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

631 PROFESSIONAL DR STE 300
LAWRENCEVILLE GA
30046-3371
US

IV. Provider business mailing address

1000 JOHNSON FY RD NE
ATLANTA GA
30342-1606
US

V. Phone/Fax

Practice location:
  • Phone: 855-709-4535
  • Fax:
Mailing address:
  • Phone: 404-851-6378
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

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