Provider Demographics
NPI:1245252220
Name:SOUTHSIDE MEDICAL CENTER, INC.
Entity type:Organization
Organization Name:SOUTHSIDE MEDICAL CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:CLAUDIO
Authorized Official - Middle Name:
Authorized Official - Last Name:AZZARITI
Authorized Official - Suffix:
Authorized Official - Credentials:MBA, CPA
Authorized Official - Phone:404-688-1350
Mailing Address - Street 1:1046 RIDGE AVE SW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30315-1640
Mailing Address - Country:US
Mailing Address - Phone:404-688-1350
Mailing Address - Fax:404-564-0431
Practice Address - Street 1:1514 CLEVELAND AVE STE 205
Practice Address - Street 2:
Practice Address - City:EAST POINT
Practice Address - State:GA
Practice Address - Zip Code:30344-6965
Practice Address - Country:US
Practice Address - Phone:678-510-0827
Practice Address - Fax:678-510-0826
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-25
Last Update Date:2010-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA044293H251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00064336AMedicaid
GA117022Medicare Oscar/Certification