Provider Demographics
NPI:1548388101
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 1:2578 GRESHAM RD SE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30316-4138
Practice Address - Country:US
Practice Address - Phone:404-564-0431
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-26
Last Update Date:2008-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA251E00000X
261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000064336AMedicaid
GA117022Medicare Oscar/Certification