1821612938 NPI number — NORTHSIDE CV PROFESSIONAL SERVICES LLC

Table of content: (NPI 1821612938)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821612938 NPI number — NORTHSIDE CV PROFESSIONAL SERVICES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHSIDE CV PROFESSIONAL SERVICES LLC
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:
Provider Other Organization Name Type Code:
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:
1821612938
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/12/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1001 SUMMIT BLVD STE 1000
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BROOKHAVEN
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30319-6415
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-851-6378
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
755 WALTHER RD
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:
30046-8725
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-962-0399
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/04/2020

Additional Information

Authorized Official

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

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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