1780924043 NPI number — WELLSTAR MEDICAL GROUP, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780924043 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:
Provider Other Organization Name Type Code:
6
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:
1780924043
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/26/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3939 ROSWELL RD
Provider Second Line Business Mailing Address:
SUITE 300
Provider Business Mailing Address City Name:
MARIETTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30062-6251
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-509-1234
Provider Business Mailing Address Fax Number:
770-509-1235

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3939 ROSWELL RD
Provider Second Line Business Practice Location Address:
SUITE 300
Provider Business Practice Location Address City Name:
MARIETTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30062-6251
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-509-1234
Provider Business Practice Location Address Fax Number:
770-509-1235
Provider Enumeration Date:
02/25/2013

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)





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