Provider Demographics
NPI:1215369715
Name:NORTHSIDE PRIMARY CARE PROFESSIONAL SERVICES, LLC
Entity Type:Organization
Organization Name:NORTHSIDE PRIMARY CARE PROFESSIONAL SERVICES, LLC
Other - Org Name:NORTHSIDE DAWSON URGENT CARE
Other - Org Type:Other Name
Authorized Official - Title/Position:VP-ADMIN, CCO
Authorized Official - Prefix:
Authorized Official - First Name:JORGE
Authorized Official - Middle Name:J
Authorized Official - Last Name:HERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-851-6378
Mailing Address - Street 1:1100 JOHNSON FERRY RD
Mailing Address - Street 2:SUITE 780
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-1709
Mailing Address - Country:US
Mailing Address - Phone:404-851-6378
Mailing Address - Fax:
Practice Address - Street 1:81 NORTHSIDE DAWSON DRIVE
Practice Address - Street 2:
Practice Address - City:DAWSONVILLE
Practice Address - State:GA
Practice Address - Zip Code:30534-7166
Practice Address - Country:US
Practice Address - Phone:855-709-4535
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTHSIDE PRIMARY CARE PROFESIONAL SERVICES, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-08-07
Last Update Date:2023-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA208D00000X, 261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty