Basic Information
| Provider Information | |||||||||
| NPI: | 1467027482 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHSIDE MEDICAL CENTER, INC. | ||||||||
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| OtherOrganizationName: | SOUTHSIDE MEDICAL CENTER SCHOOL BASED HEALTH CENTER AT KIPP VISION | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 6687 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303150687 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4046881350 | ||||||||
| FaxNumber: | 4046882962 | ||||||||
| Practice Location | |||||||||
| Address1: | 660 MCWILLIAMS RD SE | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303157544 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6789748148 | ||||||||
| FaxNumber: | 4046882962 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/21/2021 | ||||||||
| LastUpdateDate: | 10/13/2021 | ||||||||
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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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| AuthorizedOfficialCredential: | CPA | ||||||||
| NPICertificationDate: | 10/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.