1275814964 NPI number — WELLSTAR MEDICAL GROUP, LLC

Table of content: (NPI 1275814964)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275814964 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:
1275814964
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/19/2013
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 240
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:
678-403-4660
Provider Business Mailing Address Fax Number:
770-971-6994

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3939 ROSWELL RD
Provider Second Line Business Practice Location Address:
SUITE 240
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:
678-403-4660
Provider Business Practice Location Address Fax Number:
770-971-6994
Provider Enumeration Date:
09/08/2011

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: 207Q00000X , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207QG0300X , 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)





Copyright © 2007-2025 www.npivalidator.com