NPIMap

Organization Active NPI

Southside Medical Center, Inc.

  • Community/Behavioral Health Agency
  • Atlanta, GA
National Provider Identifier
1174641658
Registry record updated Jul 9, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Community/Behavioral Health AgencyTaxonomy code 251S00000X
Legal business name
SOUTHSIDE MEDICAL CENTER, INC.
Practice address
1100 Cleveland Ave
Atlanta, GA 30344-3602
Phone
(404) 627-1385
Fax
(404) 564-0377
NPI assigned
Mar 26, 2007
Last updated
Jul 9, 2025By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 9, 2025

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mr. Masresha Kassa, CPA
Title
Cfo
Phone
(404) 564-7009

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Community/Behavioral Health Agency 251S00000X GA Primary
Federally Qualified Health Center (FQHC) 261QF0400X

Addresses

Primary practice location

1100 Cleveland Ave
Atlanta, GA 30344-3602

Mailing address

1046 Ridge Ave SW
Atlanta, GA 30315-1640
Phone (404) 688-1350

Other identifiers 4

IdentifierTypeStateIssuer
GRP375OtherGAMEDICARE GROUP
000041764BMedicaidGA
000444056HMedicaidGA
04092OtherGABCBS

Other names 1

  • Southside Healthcare Former legal business name

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in GA2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20100929001648 GA Part A Provider - Federally Qualified Health Center (FQHC) 6901700723 Practice locations: Atlanta, GA
O20200201000020 GA Part B Supplier - Opioid Treatment Program (Otp) 6901700723 Practice locations: East Point, GA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1174641658. Details of each certification follow.

Federally qualified health center certification: CCN 111881

Legal name
SOUTHSIDE MEDICAL CENTER, INC.
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Jan 28, 2004
Last certification
Jan 28, 2004
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Dec 17, 1970 in GA
Enrollment address
1100 Cleveland Ave
Atlanta, GA 30344-3602

Other NPIs with the same Medicare PAC ID 14

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

View all 14

National Provider Directory

National Provider Directory

Locations

1100 Cleveland Ave
East Point, GA 30344
Phone (404) 564-6778

409 W Solomon St
Griffin, GA 30223
Phone (678) 688-8700

1030 Old Peachtree Rd NW
#402
Lawrenceville, GA 30043

Ownership & related parties

All disclosed owners & managing parties 3

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
David M Williams Individual Corporate Director Jul 2, 1990
W-2 Managing EmployeeCeo Jul 2, 1990
Brenda a Williams Individual Corporate Director Jul 26, 2010
Janis L Ware Individual Corporate Director Jul 26, 2010

Owners & managing parties with NPI records 1

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

All facility ownership & control disclosures 1

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Suncrest Home HealthAtlanta, GA, CCN 117022 Home health agency 5% Or Greater Direct Ownership Interest (100%) Mar 1, 2021

Owned or controlled facilities with NPI records 1

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Practitioners & affiliated clinicians

Practitioners 22

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 22

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1174867200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1752019200000",
    "number": "1174641658",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1046 RIDGE AVE SW",
            "city": "ATLANTA",
            "state": "GA",
            "postal_code": "303151640",
            "telephone_number": "404-688-1350",
            "fax_number": "404-688-2962"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1100 CLEVELAND AVE",
            "city": "ATLANTA",
            "state": "GA",
            "postal_code": "303443602",
            "telephone_number": "404-627-1385",
            "fax_number": "404-564-0377"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTHSIDE MEDICAL CENTER, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-03-26",
        "last_updated": "2025-07-09",
        "certification_date": "2025-07-09",
        "status": "A",
        "authorized_official_last_name": "KASSA",
        "authorized_official_first_name": "MASRESHA",
        "authorized_official_title_or_position": "CFO",
        "authorized_official_telephone_number": "404-564-7009",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_credential": "CPA"
    },
    "taxonomies": [
        {
            "code": "251S00000X",
            "taxonomy_group": "",
            "desc": "Community/Behavioral Health",
            "state": "GA",
            "license": null,
            "primary": true
        },
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE GROUP",
            "identifier": "GRP375",
            "state": "GA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "000041764B",
            "state": "GA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "000444056H",
            "state": "GA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBS",
            "identifier": "04092",
            "state": "GA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Southside Healthcare",
            "code": "4",
            "type": "Former Legal Business Name"
        }
    ]
}

Other providers in Atlanta, GA

Sources for this page

Verify at the official NPI Registry.