Wellstar Medical Group, LLC
Organization Active NPI Podiatrist · Marietta, GA
NPI 1750724902 · NPPES record last updated Nov 19, 2013
Key facts
- NPI
- 1750724902
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Podiatrist 213E00000X
- Legal business name
- WELLSTAR MEDICAL GROUP, LLC
- Practice address
- 55 Whitcher St NE
Suite 450
Marietta, GA 30060-1155 - Phone
- (770) 590-4188
- Fax
- (770) 590-4189
- NPI assigned
- Apr 8, 2013
- Organization subpart
- Yes
- Parent organization (as reported)
- WELLSTAR MEDICAL GROUP, LLC
Authorized official
- Name
- Nicole Ashe
- Title
- Executive Director of Finance
- Phone
- (470) 644-0095
Corporate family (same tax ID) 24
Practitioners 25
-
Michael Ardrey, FNP-BC
-
Lori Marie Boswell, CRNA
-
Ebon Anthony Bourne, M.D.
-
David M Cantrell, MD
-
Yoon Jeong Chang, M.D.
-
Kevin Day, MD
-
Sara J Healy, M.D.
-
Charles Hoff, MD
-
Kimberly D Hoffman-Goodson, CRNPF MS
-
Jui-En Edward Hsu, M.D.
-
Barry D Mangel, M.D.
-
David Modlin, M.D.
-
Christopher W Nickum, P.A.
-
Brenda D. Oswald, PA
-
Camilo Reyes Gelves, M.D
-
Nason Daniel Rouhizad, D.O.
-
Christen Faith Standiford, ANP-BC
-
Emily Bates Natarella, M.D.
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in GA
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| 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
- Tax ID family
- Wellstar Medical Group LLC
- Part of
- Wellstar Medical Group LLC
Locations
55 Whitcher St NE
Ste 450
Marietta, GA 30060
Phone (770) 590-4188
4441 Atlanta Rd SE
Ste 215
Smyrna, GA 30080
Phone (470) 956-4165
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Podiatrist |
213E00000X | GA | Yes |
Addresses
Primary practice location
55 Whitcher St NE
Suite 450
Marietta, GA 30060-1155
Mailing address
55 Whitcher St NE
Suite 450
Marietta, GA 30060-1155
Phone (770) 590-4188
Other names
- WellStar Podiatry
NPI Registry JSON
{
"created_epoch": "1365379200000",
"enumeration_type": "NPI-2",
"last_updated_epoch": "1384819200000",
"number": "1750724902",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "55 WHITCHER ST NE",
"address_2": "SUITE 450",
"city": "MARIETTA",
"state": "GA",
"postal_code": "300601155",
"telephone_number": "770-590-4188",
"fax_number": "770-590-4189"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "55 WHITCHER ST NE",
"address_2": "SUITE 450",
"city": "MARIETTA",
"state": "GA",
"postal_code": "300601155",
"telephone_number": "770-590-4188",
"fax_number": "770-590-4189"
}
],
"practiceLocations": [],
"basic": {
"organization_name": "WELLSTAR MEDICAL GROUP, LLC",
"organizational_subpart": "YES",
"parent_organization_legal_business_name": "WELLSTAR MEDICAL GROUP, LLC",
"enumeration_date": "2013-04-08",
"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"
},
"taxonomies": [
{
"code": "213E00000X",
"taxonomy_group": "193400000X SINGLE SPECIALTY GROUP",
"desc": "Podiatrist",
"state": "GA",
"license": null,
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": [
{
"organization_name": "WellStar Podiatry",
"code": "3",
"type": "Doing Business As"
}
]
}Other providers in Marietta, GA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Nov 19, 2013. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.