Provider Demographics
NPI:1265053110
Name:SPORTS MEDICINE SOUTH OF GWINNETT LLC
Entity type:Organization
Organization Name:SPORTS MEDICINE SOUTH OF GWINNETT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP/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:404-851-8000
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:404-851-8000
Mailing Address - Fax:
Practice Address - Street 1:1900 RIVERSIDE PKWY
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30043-5925
Practice Address - Country:US
Practice Address - Phone:770-237-3475
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-01
Last Update Date:2025-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Single Specialty