Provider Demographics
NPI:1790100170
Name:WELLSTAR MEDICAL GROUP, LLC
Entity Type:Organization
Organization Name:WELLSTAR MEDICAL GROUP, LLC
Other - Org Name:WELLSTAR KENNESAW STATE UNIVERSITY STUDENT HEALTH SERVICES
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 1:3215 CAMPUS LOOP RD NW
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144-3227
Mailing Address - Country:US
Mailing Address - Phone:470-578-6531
Mailing Address - Fax:470-578-9004
Practice Address - Street 1:3215 CAMPUS LOOP RD NW
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-3227
Practice Address - Country:US
Practice Address - Phone:470-578-6531
Practice Address - Fax:470-578-9004
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WELLSTAR MEDICAL GROUP, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-02-21
Last Update Date:2015-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA261QS1000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health