Healthcare Provider Details

I. General information

NPI: 1053789511
Provider Name (Legal Business Name): SOUTHSIDE MEDICAL CENTER, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2015
Last Update Date: 07/09/2025
Certification Date: 07/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

409 W SOLOMON ST
GRIFFIN GA
30223-2831
US

IV. Provider business mailing address

1046 RIDGE AVE SW
ATLANTA GA
30315-1640
US

V. Phone/Fax

Practice location:
  • Phone: 678-688-8700
  • Fax:
Mailing address:
  • Phone: 404-688-1350
  • Fax: 404-688-2962

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: MR. MASRESHA KASSA
Title or Position: CFO
Credential: CPA
Phone: 404-688-1350