Provider Demographics
NPI:1760893457
Name:WELLSTAR MEDICAL GROUP, LLC
Entity Type:Organization
Organization Name:WELLSTAR MEDICAL GROUP, LLC
Other - Org Name:WELLSTAR FAMILY MEDICINE AT WOODPARK PLACE
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 1:203 WOODPARK PL
Mailing Address - Street 2:BUILDING C; SUITE 100
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30188-3705
Mailing Address - Country:US
Mailing Address - Phone:770-926-4150
Mailing Address - Fax:770-926-0594
Practice Address - Street 1:203 WOODPARK PL
Practice Address - Street 2:BUILDING C; SUITE 100
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30188-3705
Practice Address - Country:US
Practice Address - Phone:770-926-4150
Practice Address - Fax:770-926-0594
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WELLSTAR MEDICAL GROUP, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-05-15
Last Update Date:2014-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty