NPIMap

Organization Active NPI

Southside Community Health Services, Inc.

  • Family Medicine Physician
  • Minneapolis, MN
National Provider Identifier
1679690952
Registry record updated Aug 7, 2026
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
Legal business name
SOUTHSIDE COMMUNITY HEALTH SERVICES, INC.
Practice address
1000 E Lake St
Minneapolis, MN 55407-1617
Phone
(612) 822-9030
Fax
(612) 821-2818
NPI assigned
Mar 23, 2007
Last updated
Aug 7, 2026By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 7, 2026

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

Authorized official

Name
Ann Cazaban
Title
Executive Director
Phone
(612) 827-7181

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 207Q00000X Primary

Addresses

Primary practice location

1000 E Lake St
Minneapolis, MN 55407-1617

Mailing address

4243 4TH Ave S
Minneapolis, MN 55409-2113
Phone (612) 821-2003

Other names 1

  • Southside Vision Clinic Other name

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20100622000332 MN Part A Provider - Federally Qualified Health Center (FQHC) 8921027228 Practice locations: Minneapolis, MN

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1679690952. Details of each certification follow.

Federally qualified health center certification: CCN 241815

Legal name
SOUTHSIDE COMMUNITY HEALTH SERVICES INC
Doing business as
SOUTHSIDE CLINIC
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Mar 14, 1994
Last certification
Mar 14, 1994
Ownership / control type
For profit – partnership
Organization structure
CorporationNon-profit
Incorporated
Jul 1, 1971 in MN
Enrollment address
324E 35TH St
Minneapolis, MN 55408-4580

Other NPIs with the same Medicare PAC ID 1

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

National Provider Directory

National Provider Directory

Locations

4243 4th Ave S
Minneapolis, MN 55409
Phone (612) 821-2003

5640 Memorial Ave N
Ste B
Stillwater, MN 55082
Phone (651) 430-1880

Ownership & related parties

All disclosed owners & managing parties 11

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

NameRoleSinceShare
Jasmine Jackson Individual Corporate DirectorBoard Member Jun 26, 2024
Yectli Huerta Individual Corporate DirectorBoard Chair Jun 2, 1975
Maby Almiron Individual Corporate DirectorBoard Member Jul 27, 2022
Sarah Jo Lynn Blonigan Individual Corporate DirectorBoard Member--Vice Chair Jul 26, 2023
Shaun Zeig Individual Corporate DirectorBoard Member--Treasurer Jun 1, 2016
John Patrikus Individual W-2 Managing EmployeeFinance Director May 22, 2023
Brian Osberg Individual Corporate OfficerBoard Member Mar 22, 2017
Alyssa Palmer Individual W-2 Managing EmployeeDirector of Primarycare Integration Nov 28, 2017
Sarah Kaspari Individual Corporate DirectorBoard Member Mar 22, 2023
Ann K Cazaban Individual Corporate DirectorExecutive Director Apr 1, 2016
W-2 Managing EmployeeExecutive Director Apr 1, 2016
Dora Palma Individual Corporate DirectorBoard Member Aug 28, 2024

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": "1174608000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1786060800000",
    "number": "1679690952",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4243 4TH AVE S",
            "city": "MINNEAPOLIS",
            "state": "MN",
            "postal_code": "554092113",
            "telephone_number": "612-821-2003",
            "fax_number": "612-821-2818"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1000 E LAKE ST",
            "city": "MINNEAPOLIS",
            "state": "MN",
            "postal_code": "554071617",
            "telephone_number": "612-822-9030",
            "fax_number": "612-821-2818"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTHSIDE COMMUNITY HEALTH SERVICES, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-03-23",
        "last_updated": "2026-08-07",
        "certification_date": "2026-08-07",
        "status": "A",
        "authorized_official_last_name": "CAZABAN",
        "authorized_official_first_name": "ANN",
        "authorized_official_title_or_position": "EXECUTIVE DIRECTOR",
        "authorized_official_telephone_number": "612-827-7181"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Southside Vision Clinic",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in Minneapolis, MN

Sources for this page

Verify at the official NPI Registry.