Healthcare Provider Details

I. General information

NPI: 1346296837
Provider Name (Legal Business Name): WELLSTAR CREEKSIDE PEDIATRICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/26/2006
Last Update Date: 07/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6095 PROFESSIONAL PKWY SUITE 100
DOUGLASVILLE GA
30134-5607
US

IV. Provider business mailing address

6095 PROFESSIONAL PKWY SUITE 100
DOUGLASVILLE GA
30134-5607
US

V. Phone/Fax

Practice location:
  • Phone: 770-920-2255
  • Fax: 770-920-9963
Mailing address:
  • Phone: 770-920-2255
  • Fax: 770-920-9963

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: NICOLE ASHE
Title or Position: EXECUTIVE DIRECTOR OF FINANCE
Credential:
Phone: 770-792-5261