Basic Information
Provider Information | |||||||||
NPI: | 1487949186 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | WELLSTAR MEDICAL GROUP, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | WELLSTAR URGENT CARE IN KENNESAW | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3805 CHEROKEE ST NW | ||||||||
Address2: |   | ||||||||
City: | KENNESAW | ||||||||
State: | GA | ||||||||
PostalCode: | 301442085 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7704265665 | ||||||||
FaxNumber: | 7704201792 | ||||||||
Practice Location | |||||||||
Address1: | 3805 CHEROKEE ST NW | ||||||||
Address2: |   | ||||||||
City: | KENNESAW | ||||||||
State: | GA | ||||||||
PostalCode: | 301442085 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7704265665 | ||||||||
FaxNumber: | 7704201792 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/10/2011 | ||||||||
LastUpdateDate: | 06/10/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ASHE | ||||||||
AuthorizedOfficialFirstName: | NICOLE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR OF FINANCE | ||||||||
AuthorizedOfficialTelephone: | 7707925261 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | WELLSTAR MEDICAL GROUP, LLC | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QU0200X |   | GA | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
No ID Information.