=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811037336
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LAUREATE MEDICAL GROUP AT NORTHSIDE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/07/2007
-----------------------------------------------------
Last Update Date | 06/02/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1110 W PEACHTREE ST NW STE 1100
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30309-3609
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-892-2131
-----------------------------------------------------
Fax | 404-215-9222
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1110 W PEACHTREE ST NW STE 1100
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30309-3609
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-892-2131
-----------------------------------------------------
Fax | 404-215-9222
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP ADMIN/CCO
-----------------------------------------------------
Name | JORGE J HERNANDEZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 404-851-6378
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------