Basic Information
| Provider Information | |||||||||
| NPI: | 1184111338 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WELLSTREET OF GEORGIA PC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | PIEDMONT URGENTCARE BY WELLSTREET | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3350 RIVERWOOD PKWY SE STE 1850 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303393300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7708093036 | ||||||||
| FaxNumber: | 4046622399 | ||||||||
| Practice Location | |||||||||
| Address1: | 10945 STATE BRIDGE RD STE 901 | ||||||||
| Address2: | |||||||||
| City: | ALPHARETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300228164 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4049960194 | ||||||||
| FaxNumber: | 7706671511 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2018 | ||||||||
| LastUpdateDate: | 06/16/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ALVORD | ||||||||
| AuthorizedOfficialFirstName: | SAMANTHA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRACTICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7705216690 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332900000X | Y | Suppliers | Non-Pharmacy Dispensing Site |
ID Information
| ID | Type | State | Issuer | Description | 003135883A | 05 | GA | MEDICAID |