Basic Information
| Provider Information | |||||||||
| NPI: | 1013330364 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WELLSTAR HEALTH SYSTEMS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1680 HOSPITAL SOUTH DR | ||||||||
| Address2: | |||||||||
| City: | AUSTELL | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301068110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4709568364 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1680 HOSPITAL SOUTH DR | ||||||||
| Address2: | |||||||||
| City: | AUSTELL | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301068110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4709568364 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2014 | ||||||||
| LastUpdateDate: | 02/24/2020 | ||||||||
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| AuthorizedOfficialLastName: | PATEL | ||||||||
| AuthorizedOfficialFirstName: | RAXIT | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 4709568364 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | 02/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 64951 | GA | N | Hospitals | General Acute Care Hospital | 261QM2500X | 64951 | GA | Y | Ambulatory Health Care Facilities | Clinic/Center | Medical Specialty |
No ID Information.