NPIMap

Organization Active NPI

Wellstar Medical Group, LLC

  • Student Health Clinic/Center
  • Kennesaw, GA
National Provider Identifier
1790100170
Registry record updated May 27, 2015
On this page

Key facts

NPPES NPI Registry
Primary specialty
Student Health Clinic/CenterTaxonomy code 261QS1000X
Legal business name
WELLSTAR MEDICAL GROUP, LLC
Practice address
3215 Campus Loop Rd NW
Kennesaw, GA 30144-3227
Phone
(470) 578-6531
Fax
(470) 578-9004
NPI assigned
Feb 21, 2014
Organization subpart
Yes
Parent organization
WELLSTAR MEDICAL GROUP, LLCAs reported in NPPES

NPPES NPI Registry

Updated by the provider on May 27, 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
Student Health Clinic/Center 261QS1000X GA Primary

Addresses

Primary practice location

3215 Campus Loop Rd NW
Kennesaw, GA 30144-3227

Mailing address

3215 Campus Loop Rd NW
Kennesaw, GA 30144-3227
Phone (470) 578-6531

Other names 1

  • WellStar Kennesaw State University Student Health Services 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 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

1700 Hospital South Dr
Ste 202
Austell, GA 30106
Phone (770) 793-7440

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": "1392940800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1432684800000",
    "number": "1790100170",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3215 CAMPUS LOOP RD NW",
            "city": "KENNESAW",
            "state": "GA",
            "postal_code": "301443227",
            "telephone_number": "470-578-6531",
            "fax_number": "470-578-9004"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3215 CAMPUS LOOP RD NW",
            "city": "KENNESAW",
            "state": "GA",
            "postal_code": "301443227",
            "telephone_number": "470-578-6531",
            "fax_number": "470-578-9004"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WELLSTAR MEDICAL GROUP, LLC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "WELLSTAR MEDICAL GROUP, LLC",
        "enumeration_date": "2014-02-21",
        "last_updated": "2015-05-27",
        "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": "261QS1000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Student Health",
            "state": "GA",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "WellStar Kennesaw State University Student Health Services",
            "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 May 27, 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.