Provider Demographics
NPI:1669429734
Name:WELLSTAR PEDIATRICS AT BROOKSTONE, LLC
Entity type:Organization
Organization Name:WELLSTAR PEDIATRICS AT BROOKSTONE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR OF FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:ASHE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-792-5261
Mailing Address - Street 1:5150 STILESBORO RD NW
Mailing Address - Street 2:SUITE 220
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30152-7744
Mailing Address - Country:US
Mailing Address - Phone:770-424-8222
Mailing Address - Fax:770-424-9962
Practice Address - Street 1:5150 STILESBORO RD NW
Practice Address - Street 2:SUITE 220
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30152-7744
Practice Address - Country:US
Practice Address - Phone:770-424-8222
Practice Address - Fax:770-424-9962
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WELLSTAR HEALTH SYSTEM, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-27
Last Update Date:2008-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty