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General NPI Number Information
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NPI Number | 1265920029
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Entity Type | Organization
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Legal Business Name | NORTHSIDE SEPC PROFESSIONAL SERVICES, LLC
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Dates
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Enumeration Date | 04/27/2018
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Last Update Date | 06/03/2025
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Provider Practice Location Address
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Address Line | 1000 JOHNSON FY RD NE
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City | ATLANTA
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State | GA
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Zip | 30342-1606
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Country | US
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Telephone | 404-851-8000
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Fax |
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Provider Business Mailing Address
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Address Line | 1100 JOHNSON FY RD NE STE 780
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City | ATLANTA
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State | GA
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Zip | 30342-1743
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | VP ADMIN. SRVS/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 | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number |
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License Number State |
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