Provider Demographics
NPI:1164715132
Name:WELLSTAR MEDICAL GROUP, LLC
Entity Type:Organization
Organization Name:WELLSTAR MEDICAL GROUP, LLC
Other - Org Name:WELLSTAR DOUGLAS SURGICAL ASSOCIATES
Other - Org Type:Doing Business As
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:470-644-0095
Mailing Address - Street 1:4904 TIMBER RIDGE DR
Mailing Address - Street 2:SUITE 104
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30135-1828
Mailing Address - Country:US
Mailing Address - Phone:770-942-4822
Mailing Address - Fax:770-942-5311
Practice Address - Street 1:4904 TIMBER RIDGE DR
Practice Address - Street 2:SUITE 104
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30135-1828
Practice Address - Country:US
Practice Address - Phone:770-942-4822
Practice Address - Fax:770-942-5311
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WELLSTAR MEDICAL GROUP, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-05-24
Last Update Date:2013-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty