Basic Information
| Provider Information | |||||||||
| NPI: | 1588088025 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHSIDE MEDICAL CENTER, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SOUTHSIDE MEDICAL CENTER - JACKSON CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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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: | 176 LYONS ST | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302332134 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4046881350 | ||||||||
| FaxNumber: | 4046882962 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/04/2014 | ||||||||
| LastUpdateDate: | 09/14/2015 | ||||||||
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| AuthorizedOfficialLastName: | WILLIAMS | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4046881350 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 000444056O | 05 | GA | MEDICAID |