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
1	261QF0400X	Federally Qualified Health Center (FQHC)

General Provider Information

NPI Number	:	1467027482
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHSIDE MEDICAL CENTER, INC.

Provider Business Mailing Address
First Line	:	PO BOX 6687
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30315-0687
Country	:	US
Telephone Number	:	404-688-1350
Fax Number	:	404-688-2962

Provider Business Practice Location Address
First Line	:	660 MCWILLIAMS RD SE
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30315-7544
Country	:	US
Telephone Number	:	678-974-8148
Fax Number	:	404-688-2962

Authorized Official
Title or Position	:	CFO
Name	:	CLAUDIO AZZARITI
Credential	:	CPA
Telephone Number	:	404-564-7009

Provider Enumeration Date	:	05/21/2021
Last Update Date	:	10/13/2021

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