Basic Information
| Provider Information | |||||||||
| NPI: | 1245252220 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHSIDE MEDICAL CENTER, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1046 RIDGE AVE SW | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303151640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4046881350 | ||||||||
| FaxNumber: | 4045640431 | ||||||||
| Practice Location | |||||||||
| Address1: | 1514 CLEVELAND AVE STE 205 | ||||||||
| Address2: | |||||||||
| City: | EAST POINT | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303446965 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6785100827 | ||||||||
| FaxNumber: | 6785100826 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2006 | ||||||||
| LastUpdateDate: | 06/10/2010 | ||||||||
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| AuthorizedOfficialLastName: | AZZARITI | ||||||||
| AuthorizedOfficialFirstName: | CLAUDIO | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 4046881350 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | MBA, CPA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | 044293H | GA | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | 00064336A | 05 | GA | MEDICAID |