1962792580 NPI number — JESSICA GONZALEZ HERNANDEZ MD

Table of content: JESSICA GONZALEZ HERNANDEZ MD (NPI 1962792580)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962792580 NPI number — JESSICA GONZALEZ HERNANDEZ MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GONZALEZ HERNANDEZ
Provider First Name:
JESSICA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

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:
1962792580
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/20/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

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

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
CAROLINA SURGICAL ASSOCIATES EASTSIDE
Provider Second Line Business Practice Location Address:
135 COMMONWEALTH DRIVE STE 210
Provider Business Practice Location Address City Name:
GREENVILLE
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29615-4850
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
864-675-4815
Provider Business Practice Location Address Fax Number:
877-893-3779
Provider Enumeration Date:
04/15/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  61156 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 611564 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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