=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619558657
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTHSIDE HOSPITAL, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/20/2021
-----------------------------------------------------
Last Update Date | 08/06/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 631 PROFESSIONAL DR STE 450
-----------------------------------------------------
City | LAWRENCEVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30046-3370
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-533-1559
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1000 JOHNSON FERRY RD
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30342-1606
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-851-6378
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CCO
-----------------------------------------------------
Name | JORGE J. HERNANDEZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 404-851-6378
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------