NPIMap

Organization Active NPI

Wellstar Medical Group, LLC

Doing business as WellStar Kennesaw Medical Center

  • Family Medicine Physician
  • Kennesaw, GA
National Provider Identifier
1376849919
Registry record updated Nov 18, 2013
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
Legal business name
WELLSTAR MEDICAL GROUP, LLC
Doing business as
WellStar Kennesaw Medical Center
Practice address
3805 Cherokee St NW
Kennesaw, GA 30144-2085
Phone
(770) 426-5666
Fax
(770) 426-9212
NPI assigned
Jan 30, 2011
Last updated
Nov 18, 2013By the provider in NPPES
Organization subpart
Yes
Parent organization
WELLSTAR MEDICAL GROUP, LLCAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Nov 18, 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 Physician 207Q00000X GA Primary
Internal Medicine Physician 207R00000X GA

Addresses

Primary practice location

3805 Cherokee St NW
Kennesaw, GA 30144-2085

Mailing address

3805 Cherokee St NW
Kennesaw, GA 30144-2085
Phone (770) 426-5666

Other names 1

  • WellStar Kennesaw Medical 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

National Provider Directory

National Provider Directory
Tax ID family
Pulmonary Wellstar125 organizations share this tax ID, including this one
Part of
Pulmonary Wellstar

Organizations with this tax ID in the same state 24

This tax ID family is large, so up to 24 of its organizations in the same state are linked here.

View all 24

Practitioners & affiliated clinicians

Practitioners 19

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 19

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": "1384732800000",
    "number": "1376849919",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3805 CHEROKEE ST NW",
            "city": "KENNESAW",
            "state": "GA",
            "postal_code": "301442085",
            "telephone_number": "770-426-5666",
            "fax_number": "770-426-9212"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3805 CHEROKEE ST NW",
            "city": "KENNESAW",
            "state": "GA",
            "postal_code": "301442085",
            "telephone_number": "770-426-5666",
            "fax_number": "770-426-9212"
        }
    ],
    "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": "2013-11-18",
        "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": "",
            "desc": "Family Medicine",
            "state": "GA",
            "license": null,
            "primary": true
        },
        {
            "code": "207R00000X",
            "taxonomy_group": "",
            "desc": "Internal Medicine",
            "state": "GA",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "WellStar Kennesaw Medical Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Kennesaw, GA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 18, 2013; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.