Wellstar Medical Group, LLC
Organization Active NPI Otolaryngology Physician · Marietta, GA
NPI 1881990455 · NPPES record last updated Jan 31, 2011
Key facts
- NPI
- 1881990455
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Otolaryngology Physician 207Y00000X
- Legal business name
- WELLSTAR MEDICAL GROUP, LLC
- Practice address
- 320 Kennestone Hospital Blvd
Suite 107
Marietta, GA 30060-1161 - Phone
- (770) 793-7613
- Fax
- (770) 793-7413
- NPI assigned
- Jan 31, 2011
- Organization subpart
- Yes
- Parent organization (as reported)
- WELLSTAR MEDICAL GROUP, LLC
Authorized official
- Name
- Mrs. Nicole Ashe
- Title
- Executive Director of Finance
- Phone
- (770) 792-5261
Corporate family (same tax ID) 22
Practitioners 16
-
Neeharika Bade, MD
-
Hamid Harrison Bakhtiary, M.D.
-
Jonathan David Beck, PAC
-
Michael Brunt, M.D.
-
Fernanda Costa, ACNPC-AG
-
Heather A Dunagan, AGNP
-
James R. Gossage, MD
-
Nasira Hussain, MD
-
Sana Muneer, MD
-
Kelly Brumbelow Nix, FNP, BC
-
Ava Tompkins Radakovich, PA-C
-
Kristen Clark Tekin, PA-C
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
148 Bill Carruth Pkwy
Ste 220
Hiram, GA 30141
Phone (770) 505-0023
320 Kennestone Hospital Blvd
Ste 107
Marietta, GA 30060
Phone (770) 793-7417
4581 S Cobb Dr SE
Ste 100
Smyrna, GA 30080
Phone (470) 956-9171
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Otolaryngology Physician |
207Y00000X | GA | Yes |
Addresses
Primary practice location
320 Kennestone Hospital Blvd
Suite 107
Marietta, GA 30060-1161
Mailing address
320 Kennestone Hospital Blvd
Suite 107
Marietta, GA 30060-1161
Phone (770) 793-7613
Other names
- WellStar Physicians Group ENT
Other providers in Marietta, GA
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- Wellstar Medical Group, LLC
- Wellstar Medical Group, LLC
- Wellstar Medical Group, LLC
- Wellstar Medical Group, LLC
- Wellstar Medical Group, LLC
- Wellstar Medical Group, LLC
- Wellstar Medical Group, LLC
- Wellstar Medical Group, LLC
- Wellstar Medical Specialist 2LLC
All providers in Marietta, GA · Otolaryngology Physician in Georgia
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jan 31, 2011. 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.