1811282502 NPI number — WELLSTAR MEDICAL GROUP, LLC

Table of content: SHARON MCKNIGHT FERNANDEZ LPN (NPI 1841809761)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811282502 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 COBB HOSPITALISTS
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:
1811282502
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/10/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3950 AUSTELL RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AUSTELL
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30106-1121
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-792-4022
Provider Business Mailing Address Fax Number:
770-732-4023

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3950 AUSTELL RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AUSTELL
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30106-1121
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-792-4022
Provider Business Practice Location Address Fax Number:
770-732-4023
Provider Enumeration Date:
06/10/2011

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:
770-792-5261

Provider Taxonomy Codes

  • Taxonomy code: 208M00000X , 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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