Basic Information
| Provider Information | |||||||||
| NPI: | 1518263656 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WELLSTAR MEDICAL GROUP, LLC | ||||||||
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| OtherOrganizationName: | WELLSTAR KENNESTONE PEDIATRIC ASSOCIATES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 121 MARBLE MILL RD NW | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300607959 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704228315 | ||||||||
| FaxNumber: | 7705909170 | ||||||||
| Practice Location | |||||||||
| Address1: | 121 MARBLE MILL RD NW | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300607959 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704228315 | ||||||||
| FaxNumber: | 7705909170 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2011 | ||||||||
| LastUpdateDate: | 11/18/2013 | ||||||||
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| AuthorizedOfficialLastName: | ASHE | ||||||||
| AuthorizedOfficialFirstName: | NICOLE | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR OF FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 4706440095 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WELLSTAR MEDICAL GROUP, LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | GA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.