Provider Demographics
NPI:1669752911
Name:WELLSTAR MEDICAL GROUP, LLC
Entity type:Organization
Organization Name:WELLSTAR MEDICAL GROUP, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
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 1:3747 ROSWELL RD NE
Mailing Address - Street 2:SUITE 212
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30062-6215
Mailing Address - Country:US
Mailing Address - Phone:678-403-4300
Mailing Address - Fax:770-999-2166
Practice Address - Street 1:3747 ROSWELL RD NE
Practice Address - Street 2:SUITE 212
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30062-6215
Practice Address - Country:US
Practice Address - Phone:678-403-4300
Practice Address - Fax:770-999-2166
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WELLSTAR MEDICAL GROUP, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-08-18
Last Update Date:2015-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Single Specialty