Healthcare Provider Details

I. General information

NPI: 1093972408
Provider Name (Legal Business Name): WELLCARE OF GEORGIA, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2008
Last Update Date: 05/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 PERIMETER CENTER PKWY NE STE 800
ATLANTA GA
30346-1308
US

IV. Provider business mailing address

8735 HENDERSON RD
TAMPA FL
33634-1143
US

V. Phone/Fax

Practice location:
  • Phone: 866-300-1141
  • Fax:
Mailing address:
  • Phone: 813-290-6200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number2005112
License Number StateGA

VIII. Authorized Official

Name: MICHAEL HABER
Title or Position: VP & SECRETARY
Credential:
Phone: 813-206-1490