Provider Demographics
NPI:1174641658
Name:SOUTHSIDE MEDICAL CENTER, INC.
Entity Type:Organization
Organization Name:SOUTHSIDE MEDICAL CENTER, INC.
Other - Org Name:SOUTHSIDE HEALTHCARE
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:CLAUDIO
Authorized Official - Middle Name:
Authorized Official - Last Name:AZZARITI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-564-7009
Mailing Address - Street 1:1046 RIDGE AVE SW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30315-1640
Mailing Address - Country:US
Mailing Address - Phone:404-688-1350
Mailing Address - Fax:404-688-2962
Practice Address - Street 1:1100 CLEVELAND AVE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30344-3602
Practice Address - Country:US
Practice Address - Phone:404-627-1385
Practice Address - Fax:404-564-0377
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-26
Last Update Date:2012-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA251S00000X
261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP375OtherMEDICARE GROUP
GA000041764BMedicaid
GA000444056HMedicaid
GA04092OtherBCBS
GA000444056HMedicaid