Provider Demographics
NPI:1467027482
Name:SOUTHSIDE MEDICAL CENTER, INC.
Entity Type:Organization
Organization Name:SOUTHSIDE MEDICAL CENTER, INC.
Other - Org Name:SOUTHSIDE MEDICAL CENTER SCHOOL BASED HEALTH CENTER AT KIPP VISION
Other - Org Type:Doing Business As
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:CPA
Authorized Official - Phone:404-564-7009
Mailing Address - Street 1:PO BOX 6687
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30315-0687
Mailing Address - Country:US
Mailing Address - Phone:404-688-1350
Mailing Address - Fax:404-688-2962
Practice Address - Street 1:660 MCWILLIAMS RD SE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30315-7544
Practice Address - Country:US
Practice Address - Phone:678-974-8148
Practice Address - Fax:404-688-2962
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-21
Last Update Date:2021-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)