Healthcare Provider Details

I. General information

NPI: 1629374681
Provider Name (Legal Business Name): WELLSTAR MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2011
Last Update Date: 11/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 CHURCH ST NE
MARIETTA GA
30060-1101
US

IV. Provider business mailing address

625 CHURCH ST NE
MARIETTA GA
30060-1101
US

V. Phone/Fax

Practice location:
  • Phone: 770-422-2004
  • Fax: 770-422-8465
Mailing address:
  • Phone: 770-422-2004
  • Fax: 770-422-8465

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number
License Number StateGA

VIII. Authorized Official

Name: MRS. NICOLE ASHE
Title or Position: EXECUTIVE DIRECTOR OF FINANCE
Credential:
Phone: 470-644-0095