MEDICARE: WELLSTAR KENNESTONE OB/GYN, 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	207V00000X	Obstetrics & Gynecology Physician

General Provider Information

NPI Number	:	1548216203
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WELLSTAR KENNESTONE OB/GYN, LLC

Provider Business Mailing Address
First Line	:	2230 TOWNE LAKE PKWY
Second Line	:	BUILDING 500, SUITE 100
City	:	WOODSTOCK
State	:	GA
Zip	:	30189-5540
Country	:	US
Telephone Number	:	678-445-5941
Fax Number	:	678-445-5950

Provider Business Practice Location Address
First Line	:	2230 TOWNE LAKE PKWY
Second Line	:	BUILDING 500, SUITE 100
City	:	WOODSTOCK
State	:	GA
Zip	:	30189-5540
Country	:	US
Telephone Number	:	678-445-5941
Fax Number	:	678-445-5950

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR OF FINANCE
Name	:	NICOLE ASHE
Credential	:
Telephone Number	:	770-792-5261

Provider Enumeration Date	:	05/25/2006
Last Update Date	:	07/14/2008

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Directions to “WELLSTAR KENNESTONE OB/GYN, LLC ” Practice Location

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