1396788428 NPI number — NORTHSIDE HOSPITAL, INC.

Table of content: (NPI 1396788428)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396788428 NPI number — NORTHSIDE HOSPITAL, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHSIDE HOSPITAL, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
NORTHSIDE GWINNETT EXTENDED CARE CENTER
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1396788428
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/18/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1000 JOHNSON FERRY ROAD, NE
Provider Second Line Business Mailing Address:
ATTN: JORGE HERNANDEZ
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30342
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-851-6378
Provider Business Mailing Address Fax Number:
678-312-3065

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
650 PROFESSIONAL DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAWRENCEVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30046-8707
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-312-3000
Provider Business Practice Location Address Fax Number:
678-312-3065
Provider Enumeration Date:
06/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HERNANDEZ
Authorized Official First Name:
JORGE
Authorized Official Middle Name:
Authorized Official Title or Position:
VP ADMIN; CCO
Authorized Official Telephone Number:
404-851-6378

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  067-460 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 781382A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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