Basic Information
| Provider Information | |||||||||
| NPI: | 1629361605 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WELLSTAR MEDICAL GROUP, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | WELLSTAR PSYCHIATRY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2540 WINDY HILL RD SE | ||||||||
| Address2: | |||||||||
| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300678605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7706441570 | ||||||||
| FaxNumber: | 7706441576 | ||||||||
| Practice Location | |||||||||
| Address1: | 2540 WINDY HILL RD SE | ||||||||
| Address2: | |||||||||
| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300678605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7706441570 | ||||||||
| FaxNumber: | 7706441576 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2011 | ||||||||
| LastUpdateDate: | 11/19/2013 | ||||||||
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| AuthorizedOfficialLastName: | ASHE | ||||||||
| AuthorizedOfficialFirstName: | NICOLE | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR OF FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 4706440095 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WELLSTAR MEDICAL GROUP, LLC | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | GA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.