NPIMap

Organization Active NPI

Southside Medical Center, Inc.

  • Federally Qualified Health Center (FQHC)
  • Atlanta, GA
National Provider Identifier
1235123993
Registry record updated Jul 9, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
SOUTHSIDE MEDICAL CENTER, INC.
Practice address
1046 Ridge Ave SW
Atlanta, GA 30315-1640
Phone
(404) 688-1350
Fax
(404) 688-2962
NPI assigned
Sep 8, 2005
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) 688-1350

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Community Health Clinic/Center 261QC1500X
Federally Qualified Health Center (FQHC) 261QF0400X GA Primary

Addresses

Primary practice location

1046 Ridge Ave SW
Atlanta, GA 30315-1640

Mailing address

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

Other identifiers 2

IdentifierTypeStateIssuer
000444056BMedicaidGA
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
O20031203000053 GA Part A Provider - Federally Qualified Health Center (FQHC) 6901700723 Practice locations: Atlanta, GA
O20031212000357 GA Part B Supplier - Clinic/Group Practice 6901700723 Receives reassigned benefits from 99 practitioners
Practice locations: Lithonia, GA; Norcross, GA; Decatur, GA; Atlanta, GA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1235123993. Details of each certification follow.

Federally qualified health center certification: CCN 111877

Legal name
SOUTHSIDE MEDICAL CENTER, INC.
Organization structure
CorporationNon-profit
Incorporated
Dec 17, 1970 in GA
Enrollment address
1046 Ridge Avenue S.W.
Atlanta, GA 30315-1640

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

1039 Ridge Ave SW
Atlanta, GA 30315
Phone (407) 761-8640

1046 Ridge Ave SW
Atlanta, GA 30315
Phone (404) 564-6942

Ownership & related parties

All disclosed owners & managing parties 4

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
Steve Barnes Individual Corporate OfficerBoard Member Sep 27, 2012
Vaughn a Reid Individual Corporate OfficerBoard Member Sep 27, 2012
Janis L Ware Individual Corporate OfficerBoard Member Sep 27, 2012

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 102

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 102

NPI Registry JSON

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

{
    "created_epoch": "1126137600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1752019200000",
    "number": "1235123993",
    "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": "1046 RIDGE AVE SW",
            "city": "ATLANTA",
            "state": "GA",
            "postal_code": "303151640",
            "telephone_number": "404-688-1350",
            "fax_number": "404-688-2962"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTHSIDE MEDICAL CENTER, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2005-09-08",
        "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": "404-688-1350",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_credential": "CPA"
    },
    "taxonomies": [
        {
            "code": "261QC1500X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Community Health",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "GA",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "000444056B",
            "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.