Provider Demographics
NPI:1548566508
Name:WELLSTAR MEDICAL GROUP, LLC
Entity Type:Organization
Organization Name:WELLSTAR MEDICAL GROUP, LLC
Other - Org Name:WELLSTAR INTERNAL MEDICINE (COUSINS)
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 1:166 VANN ST NE
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-7250
Mailing Address - Country:US
Mailing Address - Phone:770-422-7377
Mailing Address - Fax:770-421-1304
Practice Address - Street 1:166 VANN ST NE
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-7250
Practice Address - Country:US
Practice Address - Phone:770-422-7377
Practice Address - Fax:770-421-1304
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WELLSTAR MEDICAL GROUP, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-02-08
Last Update Date:2013-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty