Basic Information
| Provider Information | |||||||||
| NPI: | 1386062255 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTHSIDE HOSPITAL, INC. | ||||||||
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| OtherOrganizationName: | NORTHSIDE/DUNWOODY SURGERY CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1100 JOHNSON FERRY RD | ||||||||
| Address2: | CENTERPOINTE II, STE 920 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303421709 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4048516378 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4553 N SHALLOWFORD RD | ||||||||
| Address2: | STE. 60-C | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303386408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704551983 | ||||||||
| FaxNumber: | 7704572823 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2014 | ||||||||
| LastUpdateDate: | 03/28/2014 | ||||||||
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| AuthorizedOfficialLastName: | HERNANDEZ | ||||||||
| AuthorizedOfficialFirstName: | JORGE | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | VP/CHIEF COMPLIANCE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 4048516378 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | 044-281 | GA | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
No ID Information.