NPIMap

Organization Active NPI

Southside Medical Center, Inc.

  • Federally Qualified Health Center (FQHC)
  • Norcross, GA
National Provider Identifier
1922125574
Registry record updated Jun 12, 2008
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
5127 Jimmy Carter Blvd
Norcross, GA 30093-1619
Phone
(770) 368-3845
NPI assigned
Mar 26, 2007
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 12, 2008

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

Authorized official

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

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Clinic/Center 261Q00000X
Federally Qualified Health Center (FQHC) 261QF0400X GA Primary

Addresses

Primary practice location

5127 Jimmy Carter Blvd
Norcross, GA 30093-1619

Mailing address

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

Other identifiers 1

IdentifierTypeStateIssuer
000444056FMedicaidGA

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
O20120926000592 GA Part A Provider - Federally Qualified Health Center (FQHC) 6901700723 Practice locations: Norcross, GA

Federally qualified health center certification: CCN 111867

Legal name
SOUTHSIDE MEDICAL CENTER, INC.
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Aug 29, 2001
Last certification
Aug 29, 2001
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Dec 17, 1970 in GA
Enrollment address
5127 Jimmy Carter Blvd
Ste#205
Norcross, GA 30093-1619

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

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 Director Jul 2, 1990
W-2 Managing EmployeeCeo Jul 2, 1990
Steve Barnes Individual Corporate DirectorBoard Member May 1, 2010
Vaughn a Reid Individual Corporate DirectorBoard Member Sep 1, 2012
Janis L Ware Individual Corporate DirectorBoard 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": "1174867200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1213228800000",
    "number": "1922125574",
    "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": "5127 JIMMY CARTER BLVD",
            "city": "NORCROSS",
            "state": "GA",
            "postal_code": "300931619",
            "telephone_number": "770-368-3845"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTHSIDE MEDICAL CENTER, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-03-26",
        "last_updated": "2008-06-12",
        "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"
    },
    "taxonomies": [
        {
            "code": "261Q00000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "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": "000444056F",
            "state": "GA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Southside Healthcare",
            "code": "4",
            "type": "Former Legal Business Name"
        }
    ]
}

Other providers in Norcross, GA

Sources for this page

Verify at the official NPI Registry.