Provider Demographics
NPI:1477664613
Name:WELLSTAR PHYSICIANS GROUP ENT, LLC
Entity Type:Organization
Organization Name:WELLSTAR PHYSICIANS GROUP ENT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR OF FINANCE
Authorized Official - Prefix:
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 1:504 W MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:GA
Mailing Address - Zip Code:30132-4119
Mailing Address - Country:US
Mailing Address - Phone:770-505-7190
Mailing Address - Fax:770-793-7413
Practice Address - Street 1:504 W MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:GA
Practice Address - Zip Code:30132-4119
Practice Address - Country:US
Practice Address - Phone:770-505-7190
Practice Address - Fax:770-793-7413
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WELLSTAR HEALTH SYSTEM, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-31
Last Update Date:2008-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty