Basic Information
| Provider Information | |||||||||
| NPI: | 1396788428 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTHSIDE HOSPITAL, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | NORTHSIDE GWINNETT EXTENDED CARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 JOHNSON FERRY ROAD, NE | ||||||||
| Address2: | ATTN: JORGE HERNANDEZ | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30342 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4048516378 | ||||||||
| FaxNumber: | 6783123065 | ||||||||
| Practice Location | |||||||||
| Address1: | 650 PROFESSIONAL DR | ||||||||
| Address2: | |||||||||
| City: | LAWRENCEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300468707 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6783123000 | ||||||||
| FaxNumber: | 6783123065 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2006 | ||||||||
| LastUpdateDate: | 09/18/2019 | ||||||||
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| AuthorizedOfficialLastName: | HERNANDEZ | ||||||||
| AuthorizedOfficialFirstName: | JORGE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VP ADMIN; CCO | ||||||||
| 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 | 314000000X | 067-460 | GA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 781382A | 05 | GA | MEDICAID |