1992001952 NPI number — WELLSTAR MEDICAL GROUP, LLC

Table of content: (NPI 1992001952)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992001952 NPI number — WELLSTAR MEDICAL GROUP, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WELLSTAR MEDICAL GROUP, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
WELLSTAR KENMAR PEDIATRICS
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1992001952
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/18/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
760 KENNESAW AVE NW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARIETTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30060-6909
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-427-0183
Provider Business Mailing Address Fax Number:
770-427-0788

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
760 KENNESAW AVE NW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARIETTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30060-6909
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-427-0183
Provider Business Practice Location Address Fax Number:
770-427-0788
Provider Enumeration Date:
02/08/2011

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
ASHE
Authorized Official First Name:
NICOLE
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE DIRECTOR OF FINANCE
Authorized Official Telephone Number:
470-644-0095

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)