Provider Demographics
NPI:1023301033
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 1:4480 N COOPER LAKE RD SE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30082-4622
Mailing Address - Country:US
Mailing Address - Phone:770-333-2035
Mailing Address - Fax:770-333-2059
Practice Address - Street 1:4480 N COOPER LAKE RD SE
Practice Address - Street 2:SUITE 201
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30082-4622
Practice Address - Country:US
Practice Address - Phone:770-333-2035
Practice Address - Fax:770-333-2059
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WELLSTAR MEDICAL GROUP, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-05-24
Last Update Date:2013-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatologyGroup - Single Specialty