Basic Information
| Provider Information | |||||||||
| NPI: | 1689925745 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NSH CANCER INSTITUTE PROFESSIONAL SERVICES A LLC | ||||||||
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| OtherOrganizationName: | NSH CIPS A | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1100 JOHNSON FY RD NE | ||||||||
| Address2: | CENTER POINTE I, SUITE 510 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303421709 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1505 NORTHSIDE BLVD | ||||||||
| Address2: | SUITE 4600 | ||||||||
| City: | CUMMING | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300417623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7702055292 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2012 | ||||||||
| LastUpdateDate: | 01/24/2014 | ||||||||
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| AuthorizedOfficialLastName: | HERNANDEZ | ||||||||
| AuthorizedOfficialFirstName: | JORGE | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | VP OF ADMIN SERVICES AND CCO | ||||||||
| AuthorizedOfficialTelephone: | 4048516378 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | NORTHSIDE HOSPITAL, INC. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
No ID Information.