1174641658 NPI number — SOUTHSIDE MEDICAL CENTER, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174641658 NPI number — SOUTHSIDE MEDICAL CENTER, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHSIDE MEDICAL CENTER, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1174641658
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/09/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1046 RIDGE AVE SW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30315-1640
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-688-1350
Provider Business Mailing Address Fax Number:
404-688-2962

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1100 CLEVELAND AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ATLANTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30344-3602
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-627-1385
Provider Business Practice Location Address Fax Number:
404-564-0377
Provider Enumeration Date:
03/26/2007

Additional Information

Authorized Official

Authorized Official Last Name:
KASSA
Authorized Official First Name:
MASRESHA
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
404-564-7009

Provider Taxonomy Codes

  • Taxonomy code: 261QF0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251S00000X , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: GRP375 . This is a "MEDICARE GROUP" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 000041764B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000444056H , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 04092 . This is a "BCBS" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com