Provider Demographics
NPI:1396030078
Name:WELLSTAR MEDICAL GROUP, LLC
Entity Type:Organization
Organization Name:WELLSTAR MEDICAL GROUP, LLC
Other - Org Name:WELLSTAR URGENT CARE AT TOWNE LAKE
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:770-792-5261
Mailing Address - Street 1:120 STONEBRIDGE PKWY
Mailing Address - Street 2:SUITE 310
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30189-3767
Mailing Address - Country:US
Mailing Address - Phone:678-494-2500
Mailing Address - Fax:678-494-2629
Practice Address - Street 1:120 STONEBRIDGE PKWY
Practice Address - Street 2:SUITE 310
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30189-3767
Practice Address - Country:US
Practice Address - Phone:678-494-2500
Practice Address - Fax:678-494-2629
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WELLSTAR MEDICAL GROUP, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-06-10
Last Update Date:2011-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care