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General NPI Number Information
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NPI Number | 1760815732
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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 | 08/14/2013
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Last Update Date | 08/14/2013
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Provider Practice Location Address
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Address Line | 4550 COBB PARKWAY NORTH NW
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City | ACWORTH
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State | GA
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Zip | 30101-4180
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Country | US
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Telephone | 770-917-8142
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Fax | 770-966-8864
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Provider Business Mailing Address
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Address Line | 4550 COBB PARKWAY NORTH NW
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City | ACWORTH
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State | GA
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Zip | 30101-4180
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Country | US
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Telephone | 770-917-8142
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Fax | 770-966-8864
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR OF FINANCE
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Name | NICOLE ASHE
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Credential |
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Telephone | 770-792-5261
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number |
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License Number State | GA
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