Provider Demographics
NPI:1396788428
Name:NORTHSIDE HOSPITAL, INC.
Entity type:Organization
Organization Name:NORTHSIDE HOSPITAL, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP ADMIN; CCO
Authorized Official - Prefix:MR
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 1:1000 JOHNSON FERRY ROAD, NE
Mailing Address - Street 2:ATTN: JORGE HERNANDEZ
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342
Mailing Address - Country:US
Mailing Address - Phone:404-851-6378
Mailing Address - Fax:678-312-3065
Practice Address - Street 1:650 PROFESSIONAL DR
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-8707
Practice Address - Country:US
Practice Address - Phone:678-312-3000
Practice Address - Fax:678-312-3065
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-14
Last Update Date:2019-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA067-460314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA781382AMedicaid
115645Medicare ID - Type UnspecifiedMEDICARE