NPIMap

Organization Active NPI

Southside Medical Center, Inc.

Doing business as Southside Medical Center - Jackson Clinic

  • Federally Qualified Health Center (FQHC)
  • Jackson, GA
National Provider Identifier
1588088025
Registry record updated Sep 14, 2015
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.
Doing business as
Southside Medical Center - Jackson Clinic
Practice address
176 Lyons St
Jackson, GA 30233-2134
Phone
(404) 688-1350
Fax
(404) 688-2962
NPI assigned
Feb 4, 2014
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Sep 14, 2015

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

Authorized official

Name
Dr. David M Williams, M.D.
Title
Ceo
Phone
(404) 688-1350

Specialties & licenses 1

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

Addresses

Primary practice location

176 Lyons St
Jackson, GA 30233-2134

Mailing address

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

Other identifiers 1

IdentifierTypeStateIssuer
000444056OMedicaidGA

Other names 1

  • Southside Medical Center - Jackson Clinic Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20140707001385 GA Part A Provider - Federally Qualified Health Center (FQHC) 6901700723 Practice locations: Jackson, GA

Federally qualified health center certification: CCN 111983

Legal name
SOUTHSIDE MEDICAL CENTER, INC.
Doing business as
SOUTHSIDE MEDICAL CENTER- JACKSON CLINIC
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Jul 7, 2014
Last certification
Jul 7, 2014
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Dec 17, 1970 in GA
Enrollment address
176 Lyons Street
Jackson, GA 30233-2134

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

Member organizations 1

Organizations listed as members of this organization in the National Provider Directory.

Ownership & related parties

All disclosed owners & managing parties 8

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

NameRoleSinceShare
Warren V Cheeks Individual Corporate Officer May 5, 2014
David M Williams Individual Corporate Director May 5, 2014
W-2 Managing Employee May 5, 2014
Kenneth E Morrow Individual Corporate Officer May 5, 2014
Steve Barnes Individual Corporate Officer May 5, 2014
Gregory S Taylor Individual Corporate Officer May 5, 2014
Vaughn a Reid Individual Corporate Officer May 5, 2014
Janis L Ware Individual Corporate Officer May 5, 2014
Andrea Riggs Individual Corporate Officer May 5, 2014

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": "1391472000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1442188800000",
    "number": "1588088025",
    "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": "176 LYONS ST",
            "city": "JACKSON",
            "state": "GA",
            "postal_code": "302332134",
            "telephone_number": "404-688-1350",
            "fax_number": "404-688-2962"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTHSIDE MEDICAL CENTER, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2014-02-04",
        "last_updated": "2015-09-14",
        "status": "A",
        "authorized_official_last_name": "WILLIAMS",
        "authorized_official_first_name": "DAVID",
        "authorized_official_middle_name": "M",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "404-688-1350",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "M.D."
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "000444056O",
            "state": "GA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Southside Medical Center - Jackson Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Jackson, GA

Sources for this page

Verify at the official NPI Registry.