Healthcare Provider Details

I. General information

NPI: 1083907067
Provider Name (Legal Business Name): WELLSTAR MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2011
Last Update Date: 11/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 LACY ST NW SUITE 150
MARIETTA GA
30060-1271
US

IV. Provider business mailing address

100 LACY ST NW SUITE 150
MARIETTA GA
30060-1271
US

V. Phone/Fax

Practice location:
  • Phone: 770-793-7635
  • Fax: 770-793-7645
Mailing address:
  • Phone: 770-793-7635
  • Fax: 770-793-7645

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number StateGA

VIII. Authorized Official

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