MEDICARE: JESSICA GONZALEZ HERNANDEZ MD

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	208600000X	Surgery Physician	61156	SC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1962792580
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA GONZALEZ HERNANDEZ MD

Provider Business Mailing Address
First Line	:	PO BOX 743294
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30374-3294
Country	:	US
Telephone Number	:	787-349-0120
Fax Number	:

Provider Business Practice Location Address
First Line	:	CAROLINA SURGICAL ASSOCIATES EASTSIDE
Second Line	:	135 COMMONWEALTH DRIVE STE 210
City	:	GREENVILLE
State	:	SC
Zip	:	29615-4850
Country	:	US
Telephone Number	:	864-675-4815
Fax Number	:	877-893-3779

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/15/2011
Last Update Date	:	02/20/2019

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