Provider Demographics
NPI:1336499276
Name:NSH CANCER INSTITUTE PROFESSIONAL SERVICES G LLC
Entity Type:Organization
Organization Name:NSH CANCER INSTITUTE PROFESSIONAL SERVICES G LLC
Other - Org Name:NSH CIPS G
Other - Org Type:Other Name
Authorized Official - Title/Position:VP OD ADMIN SERVICES AND CCO
Authorized Official - Prefix:
Authorized Official - First Name:JORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:HERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-851-6378
Mailing Address - Street 1:1835 SAVOY DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30341-1072
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:134 MOUNTAINSIDE VILLAGE PKWY
Practice Address - Street 2:BLDG. 400, SUITE 100
Practice Address - City:JASPER
Practice Address - State:GA
Practice Address - Zip Code:30143-8694
Practice Address - Country:US
Practice Address - Phone:706-253-3100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTHSIDE HOSPITAL, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-09-19
Last Update Date:2013-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA=========OtherTAX ID