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General NPI Number Information
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NPI Number | 1720471931
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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 | 03/12/2015
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Last Update Date | 03/16/2015
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Provider Practice Location Address
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Address Line | 677 CHURCH ST NE SUITE 100 P
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City | MARIETTA
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State | GA
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Zip | 30060-1101
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Country | US
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Telephone | 470-793-8585
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Fax | 470-793-1970
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Provider Business Mailing Address
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Address Line | 677 CHURCH ST NE SUITE 100 P
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City | MARIETTA
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State | GA
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Zip | 30060-1101
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Country | US
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Telephone | 470-793-8585
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Fax | 470-793-1970
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR OF FINANCE
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Name | MRS. NICOLE ASHE
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Credential |
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Telephone | 470-644-0095
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number |
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 208M00000X
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Taxonomy Name | Hospitalist Physician
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License Number |
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License Number State | GA
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