Provider Demographics
NPI:1821612938
Name:NORTHSIDE CV PROFESSIONAL SERVICES LLC
Entity Type:Organization
Organization Name:NORTHSIDE CV PROFESSIONAL SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP ADMIN. SVC./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 1:1001 SUMMIT BLVD STE 1000
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:GA
Mailing Address - Zip Code:30319-6415
Mailing Address - Country:US
Mailing Address - Phone:404-851-6378
Mailing Address - Fax:
Practice Address - Street 1:755 WALTHER RD
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-8725
Practice Address - Country:US
Practice Address - Phone:770-962-0399
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-04
Last Update Date:2021-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty