Provider Demographics
NPI:1952686826
Name:WELLSTAR CARDIOVASCULAR MEDICINE, LLC
Entity Type:Organization
Organization Name:WELLSTAR CARDIOVASCULAR MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF CARDIOLOGY OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:BARRY
Authorized Official - Middle Name:D
Authorized Official - Last Name:MANGEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-424-6893
Mailing Address - Street 1:55 WHITCHER ST NE
Mailing Address - Street 2:SUITE 350
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-1155
Mailing Address - Country:US
Mailing Address - Phone:770-424-6893
Mailing Address - Fax:770-528-9938
Practice Address - Street 1:1700 HOSPITAL SOUTH DR
Practice Address - Street 2:SUITE 409
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30106-6810
Practice Address - Country:US
Practice Address - Phone:770-732-9100
Practice Address - Fax:678-819-0360
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WELLSTAR HEALTH SYSTEM, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-10-11
Last Update Date:2012-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac ElectrophysiologyGroup - Multi-Specialty
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA386693863AMedicaid
GA386693863AMedicaid