NPIMap

Organization Active NPI

Northside CV Professional Services LLC

  • Cardiovascular Disease Physician
  • Lawrenceville, GA
National Provider Identifier
1821612938
Registry record updated Jul 6, 2026
On this page

Key facts

NPPES NPI Registry
Primary specialty
Cardiovascular Disease PhysicianTaxonomy code 207RC0000X
Legal business name
NORTHSIDE CV PROFESSIONAL SERVICES LLC
Practice address
755 Walther Rd
Lawrenceville, GA 30046-8725
Phone
(770) 962-0399
NPI assigned
Jun 4, 2020
Last updated
Jul 6, 2026By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 6, 2026

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Amy E Fouts
Title
Chief Compliance Officer
Phone
(404) 851-6968

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Cardiovascular Disease PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 207RC0000X Primary

Addresses

Primary practice location

755 Walther Rd
Lawrenceville, GA 30046-8725

Mailing address

1001 Summit Blvd Ste 1000
Brookhaven, GA 30319-6415
Phone (404) 851-6378

Electronic endpoints 1

TypeEndpointUseAffiliation
CONNECT URL https://esmd.officeally.io:8291/Gateway/DocumentSubmission/2_0/NhinService/XDRRequest_Service Other Bluemark LLC / Office Ally

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in GA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20210505001504 GA Part B Supplier - Clinic/Group Practice 4880003771 Receives reassigned benefits from 55 practitioners
5 other NPIs on this enrollment
Practice locations: Decatur, GA; Lawrenceville, GA; Johns Creek, GA; Loganville, GA; Macon, GA; Peachtree Corners, GA; Snellville, GA; Suwanee, GA…

Other NPIs on the same Medicare enrollment 5

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory

Locations

4745 Nelson Brogdon Blvd
Ste 300
Buford, GA 30518
Phone (678) 841-7068

3855 Pleasant Hill Rd
Ste 250
Duluth, GA 30096
Phone (770) 497-1413

1439 Jesse Jewell Pkwy NE
Ste 202
Gainesville, GA 30501
Phone (770) 219-0023

1132 Athens Hwy
Ste 207
Grayson, GA 30017
Phone (678) 312-0300

5185 Peachtree Pkwy
Ste 240
Peachtree Corners, GA 30092
Phone (470) 242-0716

4365 Johns Creek Pkwy
Ste 450
Suwanee, GA 30024
Phone (678) 417-9873

Practitioners & affiliated clinicians

Practitioners 56

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 56

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1591228800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1783296000000",
    "number": "1821612938",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1001 SUMMIT BLVD STE 1000",
            "city": "BROOKHAVEN",
            "state": "GA",
            "postal_code": "303196415",
            "telephone_number": "404-851-6378"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "755 WALTHER RD",
            "city": "LAWRENCEVILLE",
            "state": "GA",
            "postal_code": "300468725",
            "telephone_number": "770-962-0399"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "NORTHSIDE CV PROFESSIONAL SERVICES LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2020-06-04",
        "last_updated": "2026-07-06",
        "certification_date": "2026-07-06",
        "status": "A",
        "authorized_official_last_name": "FOUTS",
        "authorized_official_first_name": "AMY",
        "authorized_official_middle_name": "E",
        "authorized_official_title_or_position": "CHIEF COMPLIANCE OFFICER",
        "authorized_official_telephone_number": "404-851-6968"
    },
    "taxonomies": [
        {
            "code": "207RC0000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Internal Medicine, Cardiovascular Disease",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [
        {
            "endpointType": "CONNECT",
            "endpointTypeDescription": "CONNECT URL",
            "endpoint": "https://esmd.officeally.io:8291/Gateway/DocumentSubmission/2_0/NhinService/XDRRequest_Service",
            "affiliation": "Y",
            "endpointDescription": "2.16.840.1.113883.3.2019.3",
            "affiliationName": "Bluemark LLC / Office Ally",
            "use": "OTHER",
            "useDescription": "Other",
            "useOtherDescription": "CMS esMD eMDR",
            "address_1": "1300 SE Cardinal Ct",
            "address_2": "Ste 190",
            "city": "Vancouver",
            "state": "WA",
            "country_code": "US",
            "postal_code": "986839683",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

Other providers in Lawrenceville, GA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 6, 2026; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.