Healthcare Provider Details

I. General information

NPI: 1912953621
Provider Name (Legal Business Name): WELLSTAR KENNESAW MEDICAL CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2006
Last Update Date: 07/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3805 CHEROKEE ST NW
KENNESAW GA
30144-2085
US

IV. Provider business mailing address

3805 CHEROKEE ST NW
KENNESAW GA
30144-2085
US

V. Phone/Fax

Practice location:
  • Phone: 770-426-5666
  • Fax: 770-426-9212
Mailing address:
  • Phone: 770-426-5666
  • Fax: 770-426-9212

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

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