NPIMap

Organization Active NPI

Wellstar Medical Group, LLC

  • Internal Medicine Physician
  • Hiram, GA
National Provider Identifier
1003112640
Registry record updated Nov 19, 2013
On this page

Key facts

NPPES NPI Registry
Primary specialty
Internal Medicine PhysicianTaxonomy code 207R00000X
Legal business name
WELLSTAR MEDICAL GROUP, LLC
Practice address
176 Charles Hardy Pkwy
Unit C
Hiram, GA 30141-1836
Phone
(678) 945-8200
Fax
(678) 945-8209
NPI assigned
Jan 30, 2011
Organization subpart
Yes
Parent organization
WELLSTAR MEDICAL GROUP, LLCAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Nov 19, 2013

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mrs. Nicole Ashe
Title
Executive Director of Finance
Phone
(470) 644-0095

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207Q00000X GA
Internal Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207R00000X GA Primary

Addresses

Primary practice location

176 Charles Hardy Pkwy
Unit C
Hiram, GA 30141-1836

Mailing address

176 Charles Hardy Pkwy
Unit C
Hiram, GA 30141-1836
Phone (678) 945-8200

Other names 1

  • WellStar East Paulding Primary Care Center Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in GA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20110127000374 GA Part B Supplier - Clinic/Group Practice 6709065402 Receives reassigned benefits from 4,219 practitioners
This NPI is an additional NPI on the enrollment

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
11D0725834Wellstar Primary Care at East Paulding176 Charles Hardy Parkway, Unit C, Hiram, GA 30141Certificate of waiverOct 14, 2026

National Provider Directory

National Provider Directory
Part of
Wellstar Medical Group LLC

Locations

176 Charles Hardy Pkwy
Unit C
Hiram, GA 30141
Phone (678) 945-8200

Practitioners & affiliated clinicians

Practitioners 37

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 37

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1296345600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1384819200000",
    "number": "1003112640",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "176 CHARLES HARDY PKWY",
            "address_2": "UNIT C",
            "city": "HIRAM",
            "state": "GA",
            "postal_code": "301411836",
            "telephone_number": "678-945-8200",
            "fax_number": "678-945-8209"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "176 CHARLES HARDY PKWY",
            "address_2": "UNIT C",
            "city": "HIRAM",
            "state": "GA",
            "postal_code": "301411836",
            "telephone_number": "678-945-8200",
            "fax_number": "678-945-8209"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WELLSTAR MEDICAL GROUP, LLC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "WELLSTAR MEDICAL GROUP, LLC",
        "enumeration_date": "2011-01-30",
        "last_updated": "2013-11-19",
        "status": "A",
        "authorized_official_last_name": "ASHE",
        "authorized_official_first_name": "NICOLE",
        "authorized_official_title_or_position": "EXECUTIVE DIRECTOR OF FINANCE",
        "authorized_official_telephone_number": "470-644-0095",
        "authorized_official_name_prefix": "Mrs."
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine",
            "state": "GA",
            "license": null,
            "primary": false
        },
        {
            "code": "207R00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Internal Medicine",
            "state": "GA",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "WellStar East Paulding Primary Care Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Hiram, GA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 19, 2013; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.