NPIMap

Organization Active NPI

Wellstar Medical Group, LLC

Doing business as WellStar Family Medicine (Governors)

  • Family Medicine Physician
  • Acworth, GA
National Provider Identifier
1689077562
Registry record updated May 28, 2015
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 Family Medicine (Governors)
Practice address
4900 Ivey Rd NW
Suite 1301
Acworth, GA 30101-4142
Phone
(770) 975-9077
Fax
(770) 790-4964
NPI assigned
Oct 6, 2014
Last updated
May 28, 2015By the provider in NPPES
Organization subpart
Yes
Parent organization
WELLSTAR MEDICAL GROUP, LLCAs reported in NPPES

NPPES NPI Registry

Updated by the provider on May 28, 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
Family Medicine Physician 207Q00000X GA Primary

Addresses

Primary practice location

4900 Ivey Rd NW
Suite 1301
Acworth, GA 30101-4142

Mailing address

4900 Ivey Rd NW
Suite 1301
Acworth, GA 30101-4142
Phone (770) 975-9077

Other names 1

  • WellStar Family Medicine (Governors) 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
Wellstar Neurosurgery Services LLC Dba Wellstar Neurosurgery126 organizations share this tax ID, including this one
Part of
Wellstar Neurosurgery Services LLC Dba Wellstar Neurosurgery

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

4900 Ivey Rd NW
Ste 1301
Acworth, GA 30101
Phone (770) 974-4655

Practitioners & affiliated clinicians

Practitioners 9

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.

NPI Registry JSON

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

{
    "created_epoch": "1412553600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1432771200000",
    "number": "1689077562",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4900 IVEY RD NW",
            "address_2": "SUITE 1301",
            "city": "ACWORTH",
            "state": "GA",
            "postal_code": "301014142",
            "telephone_number": "770-975-9077",
            "fax_number": "770-790-4964"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4900 IVEY RD NW",
            "address_2": "SUITE 1301",
            "city": "ACWORTH",
            "state": "GA",
            "postal_code": "301014142",
            "telephone_number": "770-975-9077",
            "fax_number": "770-790-4964"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WELLSTAR MEDICAL GROUP, LLC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "WELLSTAR MEDICAL GROUP, LLC",
        "enumeration_date": "2014-10-06",
        "last_updated": "2015-05-28",
        "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
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "WellStar Family Medicine (Governors)",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Acworth, GA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 28, 2015; 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.