Healthcare Provider Details

I. General information

NPI: 1992131478
Provider Name (Legal Business Name): WELLSTAR MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/17/2013
Last Update Date: 04/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 CANTON RD NE
MARIETTA GA
30060-7260
US

IV. Provider business mailing address

800 CANTON RD NE
MARIETTA GA
30060-7260
US

V. Phone/Fax

Practice location:
  • Phone: 770-424-4328
  • Fax: 770-426-9924
Mailing address:
  • Phone: 770-424-4328
  • Fax: 770-426-9924

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery 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