Healthcare Provider Details

I. General information

NPI: 1518139195
Provider Name (Legal Business Name): WELLSTAR PROFESSIONAL SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/24/2008
Last Update Date: 07/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

805 SANDY PLAINS RD WPG-CBO
MARIETTA GA
30066-6340
US

IV. Provider business mailing address

805 SANDY PLAINS RD WPG-CBO
MARIETTA GA
30066-6340
US

V. Phone/Fax

Practice location:
  • Phone: 770-792-5278
  • Fax:
Mailing address:
  • Phone: 770-792-5278
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State

VIII. Authorized Official

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