Provider Demographics
NPI:1588059653
Name:WELLSTAR MEDICAL GROUP, LLC
Entity type:Organization
Organization Name:WELLSTAR MEDICAL GROUP, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR OF FINANCE
Authorized Official - Prefix:MRS
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:ASHE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:470-644-0095
Mailing Address - Street 1:12 MEDICAL DR NE
Mailing Address - Street 2:
Mailing Address - City:CARTERSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30121-8002
Mailing Address - Country:US
Mailing Address - Phone:770-386-1000
Mailing Address - Fax:770-386-9165
Practice Address - Street 1:12 MEDICAL DR NE
Practice Address - Street 2:
Practice Address - City:CARTERSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30121-8002
Practice Address - Country:US
Practice Address - Phone:770-386-1000
Practice Address - Fax:770-386-9165
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WELLSTAR MEDICAL GROUP, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-04-05
Last Update Date:2015-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty