MEDICARE: NORTHSIDE HOSPITAL, INC.

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	261QA1903X	Ambulatory Surgical Clinic/Center	044-281	GA

General Provider Information

NPI Number	:	1386062255
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHSIDE HOSPITAL, INC.

Provider Business Mailing Address
First Line	:	1100 JOHNSON FERRY RD
Second Line	:	CENTERPOINTE II, STE 920
City	:	ATLANTA
State	:	GA
Zip	:	30342-1709
Country	:	US
Telephone Number	:	404-851-6378
Fax Number	:

Provider Business Practice Location Address
First Line	:	4553 N SHALLOWFORD RD
Second Line	:	STE. 60-C
City	:	ATLANTA
State	:	GA
Zip	:	30338-6408
Country	:	US
Telephone Number	:	770-455-1983
Fax Number	:	770-457-2823

Authorized Official
Title or Position	:	VP/CHIEF COMPLIANCE OFFICER
Name	:	MR. JORGE J HERNANDEZ
Credential	:
Telephone Number	:	404-851-6378

Provider Enumeration Date	:	03/28/2014
Last Update Date	:	03/28/2014

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