Provider Demographics
NPI:1871895821
Name:GWINNETT SURGERY CENTER, LLC
Entity type:Organization
Organization Name:GWINNETT SURGERY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position: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:404-851-6378
Mailing Address - Street 1:631 PROFESSIONAL DR
Mailing Address - Street 2:SUITE 390
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-3367
Mailing Address - Country:US
Mailing Address - Phone:770-962-9977
Mailing Address - Fax:770-339-9804
Practice Address - Street 1:631 PROFESSIONAL DR
Practice Address - Street 2:SUITE 300
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-3367
Practice Address - Country:US
Practice Address - Phone:770-962-9977
Practice Address - Fax:770-339-9804
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-24
Last Update Date:2019-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA10041103261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA330400OtherPRIMARY PHYSICIAN'S BUSINESS LICENSE