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General NPI Number Information
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NPI Number | 1609795855
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Entity Type | Organization
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Legal Business Name | WELLSTAR MEDICAL GROUP, LLC
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Dates
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Enumeration Date | 07/13/2026
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Last Update Date | 07/13/2026
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Provider Practice Location Address
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Address Line | 4900 IVEY RD NW STE 1401
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City | ACWORTH
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State | GA
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Zip | 30101-4007
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Country | US
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Telephone | 470-648-8108
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Fax |
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Provider Business Mailing Address
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Address Line | 206 OXFORD RD
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City | NEW ALBANY
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State | MS
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Zip | 38652-3115
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Country | US
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Telephone | 662-534-2227
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Fax |
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Authorized Official
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Title or Position | CREDENTIALING
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Name | LOUETTA M CODY
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Credential |
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Telephone | 470-956-4837
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number |
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License Number State |
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