Healthcare Provider Details

I. General information

NPI: 1518263656
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

121 MARBLE MILL RD NW SUITE 101
MARIETTA GA
30060-7959
US

IV. Provider business mailing address

121 MARBLE MILL RD NW SUITE 101
MARIETTA GA
30060-7959
US

V. Phone/Fax

Practice location:
  • Phone: 770-422-8315
  • Fax: 770-590-9170
Mailing address:
  • Phone: 770-422-8315
  • Fax: 770-590-9170

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number StateGA

VIII. Authorized Official

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