Healthcare Provider Details

I. General information

NPI: 1013330364
Provider Name (Legal Business Name): WELLSTAR HEALTH SYSTEMS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2014
Last Update Date: 02/24/2020
Certification Date: 02/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1680 HOSPITAL SOUTH DR
AUSTELL GA
30106-8110
US

IV. Provider business mailing address

1680 HOSPITAL SOUTH DR
AUSTELL GA
30106-8110
US

V. Phone/Fax

Practice location:
  • Phone: 470-956-8364
  • Fax:
Mailing address:
  • Phone: 470-956-8364
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number64951
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number64951
License Number StateGA

VIII. Authorized Official

Name: RAXIT R PATEL
Title or Position: PHYSICIAN
Credential: M.D.
Phone: 470-956-8364