Provider Demographics
NPI:1306110424
Name:PULMONARY WELLSTAR
Entity type:Organization
Organization Name:PULMONARY WELLSTAR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD, SUPERVISING PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MEDEL
Authorized Official - Middle Name:
Authorized Official - Last Name:REYES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-422-1372
Mailing Address - Street 1:335 SHADOWOOD PARKWAY APT 335
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30339
Mailing Address - Country:US
Mailing Address - Phone:706-333-9188
Mailing Address - Fax:
Practice Address - Street 1:55 WITCHER ST SUITE 160
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060
Practice Address - Country:US
Practice Address - Phone:770-422-1372
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-07
Last Update Date:2012-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes284300000XHospitalsSpecial Hospital