Provider Demographics
NPI:1386062255
Name:NORTHSIDE HOSPITAL, INC.
Entity type:Organization
Organization Name:NORTHSIDE HOSPITAL, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP/CHIEF COMPLIANCE OFFICER
Authorized Official - Prefix:MR
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
Mailing Address - Street 2:CENTERPOINTE II, STE 920
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-1709
Mailing Address - Country:US
Mailing Address - Phone:404-851-6378
Mailing Address - Fax:
Practice Address - Street 1:4553 N SHALLOWFORD RD
Practice Address - Street 2:STE. 60-C
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30338-6408
Practice Address - Country:US
Practice Address - Phone:770-455-1983
Practice Address - Fax:770-457-2823
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-28
Last Update Date:2014-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA044-281261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical