Healthcare Provider Details

I. General information

NPI: 1427333293
Provider Name (Legal Business Name): WELLSTAR CARDIOVASCULAR MEDICINE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2011
Last Update Date: 05/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 TRANSIT AVE SUITE 102
CANTON GA
30114-2540
US

IV. Provider business mailing address

55 WHITCHER ST NE SUITE 350
MARIETTA GA
30060-1155
US

V. Phone/Fax

Practice location:
  • Phone: 770-704-1955
  • Fax: 770-720-2388
Mailing address:
  • Phone: 770-424-6893
  • Fax: 770-528-9938

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. BARRY D MANGEL
Title or Position: CJIEF CARDIOLOGY OFFICER
Credential:
Phone: 770-424-6893