Basic Information
| Provider Information | |||||||||
| NPI: | 1174641658 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTHSIDE MEDICAL CENTER, INC. | ||||||||
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| OtherOrganizationName: | SOUTHSIDE HEALTHCARE | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1046 RIDGE AVE SW | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303151640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4046881350 | ||||||||
| FaxNumber: | 4046882962 | ||||||||
| Practice Location | |||||||||
| Address1: | 1100 CLEVELAND AVE | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303443602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4046271385 | ||||||||
| FaxNumber: | 4045640377 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/26/2007 | ||||||||
| LastUpdateDate: | 06/11/2012 | ||||||||
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| AuthorizedOfficialLastName: | AZZARITI | ||||||||
| AuthorizedOfficialFirstName: | CLAUDIO | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 4045647009 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | N | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) | 251S00000X | GA | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | GRP375 | 01 | GA | MEDICARE GROUP | OTHER | 000041764B | 05 | GA | MEDICAID | 000444056H | 05 | GA | MEDICAID | 04092 | 01 | GA | BCBS | OTHER |