Basic Information
Provider Information | |||||||||
NPI: | 1669429734 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | WELLSTAR PEDIATRICS AT BROOKSTONE, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
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OtherLastName: |   | ||||||||
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Mailing Information | |||||||||
Address1: | 5150 STILESBORO RD NW | ||||||||
Address2: | SUITE 220 | ||||||||
City: | KENNESAW | ||||||||
State: | GA | ||||||||
PostalCode: | 301527744 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7704248222 | ||||||||
FaxNumber: | 7704249962 | ||||||||
Practice Location | |||||||||
Address1: | 5150 STILESBORO RD NW | ||||||||
Address2: | SUITE 220 | ||||||||
City: | KENNESAW | ||||||||
State: | GA | ||||||||
PostalCode: | 301527744 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7704248222 | ||||||||
FaxNumber: | 7704249962 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/27/2006 | ||||||||
LastUpdateDate: | 07/14/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
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ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ASHE | ||||||||
AuthorizedOfficialFirstName: | NICOLE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR OF FINANCE | ||||||||
AuthorizedOfficialTelephone: | 7707925261 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | WELLSTAR HEALTH SYSTEM, INC. | ||||||||
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AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |   |
No ID Information.