NPIMap

Organization Active NPI

Southside Medical Center, Inc

Doing business as Southside Medical Center at Dobbs Elementary

  • Federally Qualified Health Center (FQHC)
  • Atlanta, GA
National Provider Identifier
1629510466
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
Doing business as
Southside Medical Center at Dobbs Elementary
Practice address
2025 Jonesboro Rd SE
Atlanta, GA 30315-6726
Phone
(404) 228-6770
NPI assigned
Nov 10, 2016
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 1

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

Addresses

Primary practice location

2025 Jonesboro Rd SE
Atlanta, GA 30315-6726

Mailing address

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

Other names 1

  • SOUTHSIDE MEDICAL CENTER AT DOBBS ELEMENTARY Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20170523001570 GA Part A Provider - Federally Qualified Health Center (FQHC) 6901700723 Practice locations: Atlanta, GA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1629510466. Details of each certification follow.

Federally qualified health center certification: CCN 111061

Legal name
SOUTHSIDE MEDICAL CENTER, INC.
Doing business as
SOUTHSIDE MEDICAL CENTER AT DOBBS ELEMENTARY
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
May 23, 2017
Last certification
May 23, 2017
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Dec 17, 1970 in GA
Enrollment address
2025 Jonesboro Rd SE
Atlanta, GA 30315-6726

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
Healthsouth Inc Lab18 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

2025 Jonesboro Rd SE
Atlanta, GA 30315
Phone (404) 228-6770

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 OfficerCeo Jul 2, 1990
W-2 Managing EmployeeCeo Jul 2, 1990 100%
Vaughn a Reid Individual Corporate OfficerBoard Member Sep 1, 2012
Janis L Ware Individual Corporate OfficerBoard Member Jun 1, 2009

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": "1478736000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1752019200000",
    "number": "1629510466",
    "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"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2025 JONESBORO RD SE",
            "city": "ATLANTA",
            "state": "GA",
            "postal_code": "303156726",
            "telephone_number": "404-228-6770"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTHSIDE MEDICAL CENTER, INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2016-11-10",
        "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": "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 AT DOBBS ELEMENTARY",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Atlanta, GA

Sources for this page

Verify at the official NPI Registry.