Healthcare Provider Details

I. General information

NPI: 1114849213
Provider Name (Legal Business Name): SOUTHSIDE MEDICAL CENTER, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/29/2026
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4178 SNAPFINGER WOODS DR
DECATUR GA
30035-3411
US

IV. Provider business mailing address

4178 SNAPFINGER WOODS DR
DECATUR GA
30035-3411
US

V. Phone/Fax

Practice location:
  • Phone: 470-720-5080
  • Fax:
Mailing address:
  • Phone: 470-720-5080
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: MASRESHA KASSA
Title or Position: CFO
Credential:
Phone: 404-740-9952