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)		GA

General Provider Information

NPI Number	:	1548750573
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	:

Provider Business Practice Location Address
First Line	:	540 FAYETTEVILLE RD SE
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30316-2306
Country	:	US
Telephone Number	:	404-688-1350
Fax Number	:

Authorized Official
Title or Position	:	CFO
Name	:	MR. MASRESHA KASSA
Credential	:	CPA
Telephone Number	:	404-688-1350

Provider Enumeration Date	:	05/15/2018
Last Update Date	:	07/09/2025

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