Healthcare Provider Details

I. General information

NPI: 1447206032
Provider Name (Legal Business Name): WELLSTAR INTERNAL MEDICINE ASSOCIATES OF MARIETTA, 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

320 KENNESTONE HOSPITAL BLVD SUITE 201
MARIETTA GA
30060-1161
US

IV. Provider business mailing address

320 KENNESTONE HOSPITAL BLVD SUITE 201
MARIETTA GA
30060-1161
US

V. Phone/Fax

Practice location:
  • Phone: 770-427-2457
  • Fax: 770-427-2706
Mailing address:
  • Phone: 770-427-2457
  • Fax: 770-427-2706

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
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