Healthcare Provider Details

I. General information

NPI: 1992058903
Provider Name (Legal Business Name): NSH CANCER INSTITUTE PROFESSIONAL SERVICES G LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/16/2012
Last Update Date: 12/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

308 COLISEUM DR SUITE 120
MACON GA
31217-3865
US

IV. Provider business mailing address

1835 SAVOY DR SUITE 300
ATLANTA GA
30341-1071
US

V. Phone/Fax

Practice location:
  • Phone: 478-745-4443
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State

VIII. Authorized Official

Name: JORGE J HERNANDEZ
Title or Position: VP OF ADMIN SERVICES AND CCO
Credential:
Phone: 404-851-6378