Provider Demographics
NPI:1922365808
Name:GWINNETT ADVANCED SURGERY CENTER, LLC
Entity Type:Organization
Organization Name:GWINNETT ADVANCED SURGERY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP OF ADM 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:404-851-6968
Mailing Address - Street 1:1000 JOHNSON FERRY RD NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-1606
Mailing Address - Country:US
Mailing Address - Phone:404-851-8000
Mailing Address - Fax:
Practice Address - Street 1:2306 WISTERIA DR STE 100
Practice Address - Street 2:
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-2658
Practice Address - Country:US
Practice Address - Phone:770-979-8200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-18
Last Update Date:2023-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA110161Medicare PIN