Provider Demographics
NPI:1750631792
Name:NSH CANCER INSTITUTE PROFESSIONAL SERVICES A LLC
Entity Type:Organization
Organization Name:NSH CANCER INSTITUTE PROFESSIONAL SERVICES A LLC
Other - Org Name:NSH CIPS A
Other - Org Type:Other Name
Authorized Official - Title/Position:VP OF ADMIN SERVICES AND 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 NE
Mailing Address - Street 2:CENTER PONTE I, SUITE 510
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-1709
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2545 LAWRENCEVILLE HWY
Practice Address - Street 2:SUITE 100
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-3239
Practice Address - Country:US
Practice Address - Phone:404-321-1950
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTHSIDE HOSPITAL, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-09-18
Last Update Date:2014-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA=========OtherTAX ID
GA6720960006Medicare PIN