MEDICARE: WELLSTAR MEDICAL GROUP, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207K00000X	Allergy & Immunology Physician		GA

General Provider Information

NPI Number	:	1538467303
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WELLSTAR MEDICAL GROUP, LLC

Provider Business Mailing Address
First Line	:	4480 N COOPER LAKE RD SE
Second Line	:	STE. 101
City	:	SMYRNA
State	:	GA
Zip	:	30082-4622
Country	:	US
Telephone Number	:	770-333-2027
Fax Number	:	770-333-2031

Provider Business Practice Location Address
First Line	:	4480 N COOPER LAKE RD SE
Second Line	:	STE. 101
City	:	SMYRNA
State	:	GA
Zip	:	30082-4622
Country	:	US
Telephone Number	:	770-333-2027
Fax Number	:	770-333-2031

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR OF FINANCE
Name	:	MRS. NICOLE ASHE
Credential	:
Telephone Number	:	470-644-0095

Provider Enumeration Date	:	03/03/2011
Last Update Date	:	11/19/2013

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