NPIMap

Organization Active NPI

Wellstar Medical Group, LLC

  • Pediatrics Physician
  • Kennesaw, GA
National Provider Identifier
1457771925
Registry record updated Jun 10, 2015
On this page

Key facts

NPPES NPI Registry
Primary specialty
Pediatrics PhysicianTaxonomy code 208000000X
Legal business name
WELLSTAR MEDICAL GROUP, LLC
Practice address
1180 Ernest W Barrett Pkwy NW
Suite 102B
Kennesaw, GA 30144-4534
Phone
(678) 354-2273
Fax
(770) 794-6837
NPI assigned
Apr 23, 2014
Organization subpart
Yes
Parent organization
WELLSTAR MEDICAL GROUP, LLCAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Jun 10, 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 2

Specialty (taxonomy)CodeLicenseStatePrimary
Pediatrics PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 208000000X GA Primary
Urgent Care Clinic/Center 261QU0200X GA

Addresses

Primary practice location

1180 Ernest W Barrett Pkwy NW
Suite 102B
Kennesaw, GA 30144-4534

Mailing address

1180 Ernest W Barrett Pkwy NW
Suite 102B
Kennesaw, GA 30144-4534
Phone (678) 354-2273

Other names 1

  • WellStar Pediatric After Hours Care 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
11D2080638Wellstar Pediatric After Hours1180 Ernest W Barrett Parkway, NW, Suite 102B, Kennesaw, GA 30144Certificate of waiverMar 6, 2028

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

Practitioners & affiliated clinicians

Practitioners 20

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

View all 20

NPI Registry JSON

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

{
    "created_epoch": "1398211200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1433894400000",
    "number": "1457771925",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1180 ERNEST W BARRETT PKWY NW",
            "address_2": "SUITE 102B",
            "city": "KENNESAW",
            "state": "GA",
            "postal_code": "301444534",
            "telephone_number": "678-354-2273",
            "fax_number": "770-794-6837"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1180 ERNEST W BARRETT PKWY NW",
            "address_2": "SUITE 102B",
            "city": "KENNESAW",
            "state": "GA",
            "postal_code": "301444534",
            "telephone_number": "678-354-2273",
            "fax_number": "770-794-6837"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WELLSTAR MEDICAL GROUP, LLC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "WELLSTAR MEDICAL GROUP, LLC",
        "enumeration_date": "2014-04-23",
        "last_updated": "2015-06-10",
        "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": "208000000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Pediatrics",
            "state": "GA",
            "license": null,
            "primary": true
        },
        {
            "code": "261QU0200X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Urgent Care",
            "state": "GA",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "WellStar Pediatric After Hours Care",
            "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 Jun 10, 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.