Provider Demographics
NPI:1871871160
Name:WELLSTAR MEDICAL GROUP, LLC
Entity type:Organization
Organization Name:WELLSTAR MEDICAL GROUP, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR OF FINANCE
Authorized Official - Prefix:MRS
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:ASHE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-792-5261
Mailing Address - Street 1:2513 SHALLOWFORD RD
Mailing Address - Street 2:BUILDING 100
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30066-6809
Mailing Address - Country:US
Mailing Address - Phone:770-516-3500
Mailing Address - Fax:770-516-3600
Practice Address - Street 1:2513 SHALLOWFORD RD
Practice Address - Street 2:BUILDING 100
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30066-6809
Practice Address - Country:US
Practice Address - Phone:770-516-3500
Practice Address - Fax:770-516-3600
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WELLSTAR MEDICAL GROUP, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-08-03
Last Update Date:2011-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty