NPIMap

Organization Active NPI

Southside Medical Center, Inc.

  • Federally Qualified Health Center (FQHC)
  • Atlanta, GA
National Provider Identifier
1467027482
Registry record updated Oct 13, 2021
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
660 McWilliams Rd SE
Atlanta, GA 30315-7544
Phone
(678) 974-8148
Fax
(404) 688-2962
NPI assigned
May 21, 2021
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 13, 2021

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

Authorized official

Name
Claudio Azzariti, CPA
Title
Cfo
Phone
(404) 564-7009

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X Primary

Addresses

Primary practice location

660 McWilliams Rd SE
Atlanta, GA 30315-7544

Mailing address

PO Box 6687
Atlanta, GA 30315-0687
Phone (404) 688-1350

Other names 1

  • Southside Medical Center School Based Health Center at Kipp Vision Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in GA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20211025001256 GA Part A Provider - Federally Qualified Health Center (FQHC) 6901700723 Practice locations: Atlanta, GA

Federally qualified health center certification: CCN 851063

Legal name
SOUTHSIDE MEDICAL CENTER, INC.
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Oct 20, 2021
Last certification
Oct 20, 2021
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Dec 17, 1970 in GA
Enrollment address
660 McWilliams Rd SE
Atlanta, GA 30315-7544

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
Tax ID family
Southside Healthcare in18 organizations share this tax ID, including this one

Other organizations with this tax ID 17

Organizations that report the same tax identification number in the National Provider Directory.

View all 17

Locations

660 McWilliams Rd SE
Atlanta, GA 30315
Phone (678) 974-8148

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 OfficerCeo 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.

NPI Registry JSON

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

{
    "created_epoch": "1621555200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1634083200000",
    "number": "1467027482",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 6687",
            "city": "ATLANTA",
            "state": "GA",
            "postal_code": "303150687",
            "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": "660 MCWILLIAMS RD SE",
            "city": "ATLANTA",
            "state": "GA",
            "postal_code": "303157544",
            "telephone_number": "678-974-8148",
            "fax_number": "404-688-2962"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTHSIDE MEDICAL CENTER, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2021-05-21",
        "last_updated": "2021-10-13",
        "certification_date": "2021-10-13",
        "status": "A",
        "authorized_official_last_name": "AZZARITI",
        "authorized_official_first_name": "CLAUDIO",
        "authorized_official_title_or_position": "CFO",
        "authorized_official_telephone_number": "404-564-7009",
        "authorized_official_credential": "CPA"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Southside Medical Center School Based Health Center at Kipp Vision",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Atlanta, GA

Sources for this page

Verify at the official NPI Registry.