Healthcare Provider Details

I. General information

NPI: 1174641658
Provider Name (Legal Business Name): SOUTHSIDE MEDICAL CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/26/2007
Last Update Date: 07/09/2025
Certification Date: 07/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 CLEVELAND AVE
ATLANTA GA
30344-3602
US

IV. Provider business mailing address

1046 RIDGE AVE SW
ATLANTA GA
30315-1640
US

V. Phone/Fax

Practice location:
  • Phone: 404-627-1385
  • Fax: 404-564-0377
Mailing address:
  • Phone: 404-688-1350
  • Fax: 404-688-2962

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: MR. MASRESHA KASSA
Title or Position: CFO
Credential: CPA
Phone: 404-564-7009