Basic Information
| Provider Information | |||||||||
| NPI: | 1821612938 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTHSIDE CV PROFESSIONAL SERVICES LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1001 SUMMIT BLVD STE 1000 | ||||||||
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| City: | BROOKHAVEN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303196415 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4048516378 | ||||||||
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| Practice Location | |||||||||
| Address1: | 755 WALTHER RD | ||||||||
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| City: | LAWRENCEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300468725 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709620399 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2020 | ||||||||
| LastUpdateDate: | 08/12/2021 | ||||||||
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| AuthorizedOfficialLastName: | HERNANDEZ | ||||||||
| AuthorizedOfficialFirstName: | JORGE | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | VP ADMIN. SVC./CCO | ||||||||
| AuthorizedOfficialTelephone: | 4048516378 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 08/12/2021 | ||||||||
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.