Healthcare Provider Details

I. General information

NPI: 1154240315
Provider Name (Legal Business Name): WELLSTAR MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2026
Last Update Date: 07/13/2026
Certification Date: 07/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 E CROSSVILLE RD STE 180
ROSWELL GA
30075-5909
US

IV. Provider business mailing address

206 OXFORD RD
NEW ALBANY MS
38652-3115
US

V. Phone/Fax

Practice location:
  • Phone: 470-233-7630
  • Fax:
Mailing address:
  • Phone: 662-534-2227
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: LOUETTA M CODY
Title or Position: CREDENTIALING
Credential:
Phone: 470-956-4837