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General NPI Number Information
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NPI Number | 1821612938
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Entity Type | Organization
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Legal Business Name | NORTHSIDE CV PROFESSIONAL SERVICES LLC
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Dates
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Enumeration Date | 06/04/2020
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Last Update Date | 06/02/2025
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Provider Practice Location Address
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Address Line | 755 WALTHER RD
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City | LAWRENCEVILLE
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State | GA
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Zip | 30046-8725
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Country | US
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Telephone | 770-962-0399
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Fax |
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Provider Business Mailing Address
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Address Line | 1001 SUMMIT BLVD STE 1000
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City | BROOKHAVEN
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State | GA
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Zip | 30319-6415
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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. SVC./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 | 207RC0000X
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Taxonomy Name | Cardiovascular Disease Physician
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License Number |
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License Number State |
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