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General NPI Number Information
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NPI Number | 1215369715
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Entity Type | Organization
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Legal Business Name | NORTHSIDE PRIMARY CARE PROFESSIONAL SERVICES, LLC
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Dates
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Enumeration Date | 08/07/2013
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Last Update Date | 01/11/2023
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Provider Practice Location Address
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Address Line | 81 NORTHSIDE DAWSON DRIVE
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City | DAWSONVILLE
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State | GA
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Zip | 30534-7166
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Country | US
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Telephone | 855-709-4535
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Fax |
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Provider Business Mailing Address
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Address Line | 1100 JOHNSON FERRY RD SUITE 780
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City | ATLANTA
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State | GA
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Zip | 30342-1709
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Country | US
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Telephone | 404-851-6378
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Fax |
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Authorized Official
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Title or Position | VP-ADMIN, CCO
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Name | JORGE J. HERNANDEZ
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Credential |
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Telephone | 404-851-6378
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number |
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 261QU0200X
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Taxonomy Name | Urgent Care Clinic/Center
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License Number |
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License Number State | GA
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