Healthcare Provider Details

I. General information

NPI: 1134125420
Provider Name (Legal Business Name): PHILLIP KEVIN WELLS DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2005
Last Update Date: 09/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 PERRY HWY
HAWKINSVILLE GA
31036-6748
US

IV. Provider business mailing address

PO BOX 1297
HAWKINSVILLE GA
31036-7297
US

V. Phone/Fax

Practice location:
  • Phone: 478-783-0200
  • Fax: 478-783-0802
Mailing address:
  • Phone: 478-892-0530
  • Fax: 478-783-0802

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number052653
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: