Healthcare Provider Details

I. General information

NPI: 1326486457
Provider Name (Legal Business Name): WELLSTAR MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2013
Last Update Date: 05/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 WHITCHER ST NE SUITE 350
MARIETTA GA
30060-1129
US

IV. Provider business mailing address

55 WHITCHER ST NE SUITE 350
MARIETTA GA
30060-1129
US

V. Phone/Fax

Practice location:
  • Phone: 770-424-6893
  • Fax: 770-528-9938
Mailing address:
  • Phone: 770-424-6893
  • Fax: 770-528-9938

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number StateGA

VIII. Authorized Official

Name: MRS. NICOLE ASHE
Title or Position: EXECUTIVE DIRECTOR OF FINANCE
Credential:
Phone: 47064400953