Basic Information
| Provider Information | |||||||||
| NPI: | 1891265773 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WELLSTREET OF GEORGIA PC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | PIEDMONT URGENTCARE BY WELLSTREET | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 3350 RIVERWOOD PKWY SE STE 1850 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303393300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7708093036 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1155 CONCORD RD SE STE 200 | ||||||||
| Address2: | |||||||||
| City: | SMYRNA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300804207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7708093036 | ||||||||
| FaxNumber: | 4046622399 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/04/2018 | ||||||||
| LastUpdateDate: | 11/13/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DAVIS | ||||||||
| AuthorizedOfficialFirstName: | TONIA | ||||||||
| AuthorizedOfficialMiddleName: | RANA | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 7708093036 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | N | Ambulatory Health Care Facilities | Clinic/Center | 332900000X | Y | Suppliers | Non-Pharmacy Dispensing Site |
ID Information
| ID | Type | State | Issuer | Description | 003137211A | 05 | GA | MEDICAID |