Healthcare Provider Details

I. General information

NPI: 1861129850
Provider Name (Legal Business Name): SOUTHSIDE MEDICAL CENTER, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/01/2022
Last Update Date: 11/30/2022
Certification Date: 11/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1030 OLD PEACHTREE RD NW STE 402
LAWRENCEVILLE GA
30043-3308
US

IV. Provider business mailing address

1046 RIDGE AVE SW
ATLANTA GA
30315-1640
US

V. Phone/Fax

Practice location:
  • Phone: 770-495-6222
  • Fax: 770-495-9959
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: CLAUDIO AZZARITI
Title or Position: CFO
Credential:
Phone: 404-564-7009