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	251E00000X	Home Health Agency	044293H	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1245252220
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	:	404-564-0431

Provider Business Practice Location Address
First Line	:	1514 CLEVELAND AVE STE 205
Second Line	:
City	:	EAST POINT
State	:	GA
Zip	:	30344-6965
Country	:	US
Telephone Number	:	678-510-0827
Fax Number	:	678-510-0826

Authorized Official
Title or Position	:	CHIEF FINANCIAL OFFICER
Name	:	MR. CLAUDIO AZZARITI
Credential	:	MBA, CPA
Telephone Number	:	404-688-1350

Provider Enumeration Date	:	07/25/2006
Last Update Date	:	06/10/2010

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