NPIMap

Organization Active NPI

Southside Medical Center, Inc.

  • Federally Qualified Health Center (FQHC)
  • Forest Park, GA
National Provider Identifier
1730207663
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
4945 Governors Dr
Forest Park, GA 30297-2134
Phone
(470) 426-8028
NPI assigned
Mar 27, 2007
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) 564-7009

Specialties & licenses 1

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

Addresses

Primary practice location

4945 Governors Dr
Forest Park, GA 30297-2134

Mailing address

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

Other identifiers 1

IdentifierTypeStateIssuer
000444056EMedicaidGA

Other names 1

  • Southside Healthcare Former legal business name

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20031229000661 GA Part A Provider - Federally Qualified Health Center (FQHC) 6901700723 Practice locations: Forest Park, GA

Federally qualified health center certification: CCN 111880

Legal name
SOUTHSIDE MEDICAL CENTER, INC.
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Jan 28, 2004
Last certification
Jan 28, 2004
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Dec 17, 1970 in GA
Enrollment address
4945 Governors Dr
Forest Park, GA 30297-2134

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

Locations

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

Ownership & related parties

All disclosed owners & managing parties 9

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 Sep 1, 2012
David M Williams Individual Corporate DirectorCeo Jul 2, 1990
W-2 Managing Employee May 6, 2004
Brenda a Williams Individual Corporate Director Jul 26, 2010
Kenneth E Morrow Individual Corporate Officer Sep 1, 2012
Steve Barnes Individual Corporate Officer May 1, 2010
Gregory S Taylor Individual Corporate Officer May 1, 2010
Vaughn a Reid Individual Corporate Officer Sep 1, 2012
Janis L Ware Individual Corporate Officer Jun 1, 2009
Andrea Riggs Individual Corporate Officer Mar 1, 2013

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": "1174953600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1752019200000",
    "number": "1730207663",
    "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": "4945 GOVERNORS DR",
            "city": "FOREST PARK",
            "state": "GA",
            "postal_code": "302972134",
            "telephone_number": "470-426-8028"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTHSIDE MEDICAL CENTER, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-03-27",
        "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": "404-564-7009",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_credential": "CPA"
    },
    "taxonomies": [
        {
            "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": "000444056E",
            "state": "GA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Southside Healthcare",
            "code": "4",
            "type": "Former Legal Business Name"
        }
    ]
}

Other providers in Forest Park, GA

Sources for this page

Verify at the official NPI Registry.