Basic Information
| Provider Information | |||||||||
| NPI: | 1760798458 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WELLSTAR NEUROSURGERY SERVICES, LLC DBA WELLSTAR NEUROSURGERY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 61 WHITCHER STREET | ||||||||
| Address2: | SUITE 3110 | ||||||||
| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30060 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704222326 | ||||||||
| FaxNumber: | 7704227797 | ||||||||
| Practice Location | |||||||||
| Address1: | 61 WHITCHER STREET | ||||||||
| Address2: | SUITE 3110 | ||||||||
| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30060 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704222326 | ||||||||
| FaxNumber: | 7704227797 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2010 | ||||||||
| LastUpdateDate: | 11/23/2011 | ||||||||
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| AuthorizedOfficialLastName: | ROPER | ||||||||
| AuthorizedOfficialFirstName: | PAM | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGED CARE REPRESENTATIVE | ||||||||
| AuthorizedOfficialTelephone: | 7707925276 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207T00000X | 059122 | GA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Neurological Surgery |
No ID Information.