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NPI Code Detail

MEDICARE: SOUTHSIDE MEDICAL CENTER, INC.

MEDICARE: SOUTHSIDE MEDICAL CENTER, INC.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1261QC1500XCommunity Health Clinic/Center
2261QF0400XFederally Qualified Health Center (FQHC)GA

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
204092OTHERGABCBS

General Provider Information

NPI Number : 1235123993
Entity Type Code : Organization
Provider Name (Legal Business Name) : SOUTHSIDE MEDICAL CENTER, INC.
Provider Business Mailing Address
First Line : 1046 RIDGE AVE SW
Second Line :
City : ATLANTA
State : GA
Zip : 30315-1640
Country : US
Telephone Number : 404-688-1350
Fax Number : 404-688-2962
Provider Business Practice Location Address
First Line : 1046 RIDGE AVE SW
Second Line :
City : ATLANTA
State : GA
Zip : 30315-1640
Country : US
Telephone Number : 404-688-1350
Fax Number : 404-688-2962
Authorized Official
Title or Position : CFO
Name : MR. MASRESHA KASSA
Credential : CPA
Telephone Number : 404-688-1350
Provider Enumeration Date : 09/08/2005
Last Update Date : 07/09/2025

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Directions to “SOUTHSIDE MEDICAL CENTER, INC. ” Practice Location

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