=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396791679
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WELLSTAR WEST COBB MEDICAL CENTER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/26/2006
-----------------------------------------------------
Last Update Date | 07/14/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3707 LARGENT WAY NW
-----------------------------------------------------
City | MARIETTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30064-1672
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-581-5729
-----------------------------------------------------
Fax | 678-581-5719
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3707 LARGENT WAY NW
-----------------------------------------------------
City | MARIETTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30064-1672
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-581-5729
-----------------------------------------------------
Fax | 678-581-5719
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR OF FINANCE
-----------------------------------------------------
Name | NICOLE ASHE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 770-792-5261
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------