MEDICARE: NSH CANCER INSTITUTE PROFESSIONAL SERVICES G LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies

General Provider Information

NPI Number	:	1336499276
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NSH CANCER INSTITUTE PROFESSIONAL SERVICES G LLC

Provider Business Mailing Address
First Line	:	1835 SAVOY DR
Second Line	:	SUITE 300
City	:	ATLANTA
State	:	GA
Zip	:	30341-1072
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	134 MOUNTAINSIDE VILLAGE PKWY
Second Line	:	BLDG. 400, SUITE 100
City	:	JASPER
State	:	GA
Zip	:	30143-8694
Country	:	US
Telephone Number	:	706-253-3100
Fax Number	:

Authorized Official
Title or Position	:	VP OD ADMIN SERVICES AND CCO
Name	:	JORGE HERNANDEZ
Credential	:
Telephone Number	:	404-851-6378

Provider Enumeration Date	:	09/19/2012
Last Update Date	:	01/16/2013

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