Basic Information
| Provider Information | |||||||||
| NPI: | 1306185491 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GWINNETT CARDIOLOGY SERVICES LLC | ||||||||
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| OtherOrganizationName: | CARDIOVASCULAR GROUP PC | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 JOHNSON FERRY ROAD | ||||||||
| Address2: | ATTN: JORGE HERNANDEZ | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303421170 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4048516378 | ||||||||
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| Practice Location | |||||||||
| Address1: | 755 WALTHER RD | ||||||||
| Address2: | |||||||||
| City: | LAWRENCEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300468725 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6783125625 | ||||||||
| FaxNumber: | 7703393459 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2013 | ||||||||
| LastUpdateDate: | 08/28/2019 | ||||||||
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| AuthorizedOfficialLastName: | HERNANDEZ | ||||||||
| AuthorizedOfficialFirstName: | JORGE | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP ADMIN; CCO | ||||||||
| AuthorizedOfficialTelephone: | 4048516378 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | NORTHSIDE HOSPITAL, INC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
No ID Information.