Healthcare Provider Details

I. General information

NPI: 1972559805
Provider Name (Legal Business Name): WELLSTAR MARIETTA INTERNAL MEDICINE, 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

54 TOWER RD NE
MARIETTA GA
30060-6977
US

IV. Provider business mailing address

54 TOWER RD NE
MARIETTA GA
30060-6977
US

V. Phone/Fax

Practice location:
  • Phone: 770-427-4682
  • Fax: 770-499-8562
Mailing address:
  • Phone: 770-427-4682
  • Fax: 770-499-8562

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