Healthcare Provider Details

I. General information

NPI: 1881990455
Provider Name (Legal Business Name): WELLSTAR MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2011
Last Update Date: 01/31/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 KENNESTONE HOSPITAL BLVD SUITE 107
MARIETTA GA
30060-1161
US

IV. Provider business mailing address

320 KENNESTONE HOSPITAL BLVD SUITE 107
MARIETTA GA
30060-1161
US

V. Phone/Fax

Practice location:
  • Phone: 770-793-7613
  • Fax: 770-793-7413
Mailing address:
  • Phone: 770-793-7613
  • Fax: 770-793-7413

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number
License Number StateGA

VIII. Authorized Official

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