Healthcare Provider Details

I. General information

NPI: 1871871160
Provider Name (Legal Business Name): WELLSTAR MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2011
Last Update Date: 09/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2513 SHALLOWFORD RD BUILDING 100
MARIETTA GA
30066-6809
US

IV. Provider business mailing address

2513 SHALLOWFORD RD BUILDING 100
MARIETTA GA
30066-6809
US

V. Phone/Fax

Practice location:
  • Phone: 770-516-3500
  • Fax: 770-516-3600
Mailing address:
  • Phone: 770-516-3500
  • Fax: 770-516-3600

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateGA

VIII. Authorized Official

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