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)
2	251S00000X	Community/Behavioral Health Agency		GA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	GRP375	OTHER	GA	MEDICARE GROUP

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	04092	OTHER	GA	BCBS

General Provider Information

NPI Number	:	1174641658
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	:	404-688-2962

Provider Business Practice Location Address
First Line	:	1100 CLEVELAND AVE
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30344-3602
Country	:	US
Telephone Number	:	404-627-1385
Fax Number	:	404-564-0377

Authorized Official
Title or Position	:	CFO
Name	:	MR. MASRESHA KASSA
Credential	:	CPA
Telephone Number	:	404-564-7009

Provider Enumeration Date	:	03/26/2007
Last Update Date	:	07/09/2025

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Directions to “SOUTHSIDE MEDICAL CENTER, INC. ” Practice Location

Language	Start Address	Practice Location

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