1174641658 NPI number — SOUTHSIDE MEDICAL CENTER, INC.

Table of content: (NPI 1174641658)

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:
SOUTHSIDE HEALTHCARE
Provider Other Organization Name Type Code:
4
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:
06/11/2012
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:
AZZARITI
Authorized Official First Name:
CLAUDIO
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
404-564-7009

Provider Taxonomy Codes

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

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".