NPIMap

Organization Active NPI

Wellstar Medical Group, LLC

  • Endocrinology, Diabetes & Metabolism Physician
  • Austell, GA
National Provider Identifier
1457766339
Registry record updated Dec 7, 2015
On this page

Key facts

NPPES NPI Registry
Primary specialty
Endocrinology, Diabetes & Metabolism PhysicianTaxonomy code 207RE0101X
Legal business name
WELLSTAR MEDICAL GROUP, LLC
Practice address
3825 Medical Park Dr
Suite 100
Austell, GA 30106-6831
Phone
(770) 941-8100
Fax
(770) 948-0771
NPI assigned
Jun 30, 2014
Organization subpart
Yes
Parent organization
WELLSTAR MEDICAL GROUP, LLCAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Dec 7, 2015

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 1

Specialty (taxonomy)CodeLicenseStatePrimary
Endocrinology, Diabetes & Metabolism PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 207RE0101X GA Primary

Addresses

Primary practice location

3825 Medical Park Dr
Suite 100
Austell, GA 30106-6831

Mailing address

3825 Medical Park Dr
Suite 100
Austell, GA 30106-6831
Phone (770) 941-8100

Other names 1

  • WellStar Endocrinology (Austell) 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
11D2087324Wellstar Endocrinology Austell3825 Medical Park Drive Ste 200, Austell, GA 30106Certificate of waiverNov 20, 2026

National Provider Directory

National Provider Directory
Tax ID family
Wellstar Medical Group LLC125 organizations share this tax ID, including this one
Part of
Wellstar Medical Group LLC

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

Locations

3747 Roswell Rd
Ste 212
Marietta, GA 30062
Phone (678) 403-4300

Practitioners & affiliated clinicians

Practitioners 10

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

NPI Registry JSON

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

{
    "created_epoch": "1404086400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1449446400000",
    "number": "1457766339",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3825 MEDICAL PARK DR",
            "address_2": "SUITE 100",
            "city": "AUSTELL",
            "state": "GA",
            "postal_code": "301066831",
            "telephone_number": "770-941-8100",
            "fax_number": "770-948-0771"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3825 MEDICAL PARK DR",
            "address_2": "SUITE 100",
            "city": "AUSTELL",
            "state": "GA",
            "postal_code": "301066831",
            "telephone_number": "770-941-8100",
            "fax_number": "770-948-0771"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WELLSTAR MEDICAL GROUP, LLC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "WELLSTAR MEDICAL GROUP, LLC",
        "enumeration_date": "2014-06-30",
        "last_updated": "2015-12-07",
        "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": "207RE0101X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Internal Medicine, Endocrinology, Diabetes & Metabolism",
            "state": "GA",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "WellStar Endocrinology (Austell)",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Austell, GA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 7, 2015; 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.