Basic Information
| Provider Information | |||||||||
| NPI: | 1659656403 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WELLSTAR CARDIOVASCULAR MEDICINE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 55 WHITCHER ST NE | ||||||||
| Address2: | SUITE 350 | ||||||||
| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300601155 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704246893 | ||||||||
| FaxNumber: | 7705289938 | ||||||||
| Practice Location | |||||||||
| Address1: | 148 BILL CARRUTH PKWY | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | HIRAM | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301413754 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6783244444 | ||||||||
| FaxNumber: | 7705289932 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2011 | ||||||||
| LastUpdateDate: | 05/09/2012 | ||||||||
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| AuthorizedOfficialLastName: | MANGEL | ||||||||
| AuthorizedOfficialFirstName: | BARRY | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF CARDIOLOGY OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 7704246893 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WELLSTAR HEALTH SYSTEM, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0001X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Clinical Cardiac Electrophysiology | 207RI0011X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology | 207RC0000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 386693863A | 05 | GA | MEDICAID |