Basic Information
| Provider Information | |||||||||
| NPI: | 1780076927 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GWINNETT HOSPITAL SYSTEM GME, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 JOHNSON FERRY RD | ||||||||
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| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303421611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4048516378 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1000 MEDICAL CENTER BLVD | ||||||||
| Address2: | |||||||||
| City: | LAWRENCEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300467694 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6783121000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/25/2015 | ||||||||
| LastUpdateDate: | 08/28/2019 | ||||||||
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| AuthorizedOfficialLastName: | HERNANDEZ | ||||||||
| AuthorizedOfficialFirstName: | JORGE | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP ADMIN; CCO | ||||||||
| AuthorizedOfficialTelephone: | 4048516378 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | NORTHSIDE HOSPITAL, INC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207V00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.