Provider Demographics
NPI:1760798458
Name:WELLSTAR NEUROSURGERY SERVICES, LLC DBA WELLSTAR NEUROSURGERY
Entity Type:Organization
Organization Name:WELLSTAR NEUROSURGERY SERVICES, LLC DBA WELLSTAR NEUROSURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGED CARE REPRESENTATIVE
Authorized Official - Prefix:
Authorized Official - First Name:PAM
Authorized Official - Middle Name:
Authorized Official - Last Name:ROPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-792-5276
Mailing Address - Street 1:61 WHITCHER STREET
Mailing Address - Street 2:SUITE 3110
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060
Mailing Address - Country:US
Mailing Address - Phone:770-422-2326
Mailing Address - Fax:770-422-7797
Practice Address - Street 1:61 WHITCHER STREET
Practice Address - Street 2:SUITE 3110
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060
Practice Address - Country:US
Practice Address - Phone:770-422-2326
Practice Address - Fax:770-422-7797
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-19
Last Update Date:2011-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA059122207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1760775738Medicare PIN
GA1285778613Medicare PIN