Wellstar Medical Group, LLC
Organization Active NPI Family Medicine Physician · Roswell, GA
NPI 1922405729 · NPPES record last updated Feb 18, 2015
Key facts
- NPI
- 1922405729
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Family Medicine Physician 207Q00000X
- Legal business name
- WELLSTAR MEDICAL GROUP, LLC
- Practice address
- 11685 Alpharetta Hwy
Suite 300
Roswell, GA 30076-4910 - Phone
- (678) 325-6611
- Fax
- (678) 325-6616
- NPI assigned
- Nov 24, 2014
- Organization subpart
- Yes
- Parent organization (as reported)
- WELLSTAR MEDICAL GROUP, LLC
Authorized official
- Name
- Mrs. Nicole Ashe
- Title
- Executive Director of Finance
- Phone
- (470) 644-0095
Corporate family (same tax ID) 19
Practitioners 16
-
Larry D Jowers, PA-C
-
Jinu Pravin Kamdar, M.D.
-
Erin Mezzetti, PA
-
Jaymin Patel, M.D.
-
Julie A Porter, CNM
-
Melissa Hayden Shafer, PA-C
-
Donald Lance Smallwood, D.O.
-
Daniel Marc Toubiana, PA-C
-
Praveen Vemula, MD
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
4550 Cobb Parkway North NW
Ste 101
Acworth, GA 30101
Phone (470) 956-0100
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician |
207Q00000X | GA | Yes |
Addresses
Primary practice location
11685 Alpharetta Hwy
Suite 300
Roswell, GA 30076-4910
Mailing address
11685 Alpharetta Hwy
Suite 300
Roswell, GA 30076-4910
Phone (678) 325-6611
Other names
- WellStar Family Medicine (Willow Creek)
Other providers in Roswell, GA
- Wellness IV Spa & Medical Weight Loss Center
- Wellnessone of Roswell
- Katherine Wells
- Wellspring Counseling Center
- Wellstar Medical Group, LLC
- Wellstar North Fulton Hospital, Inc
- Wellstar North Fulton Hospital, Inc
- Wellstar North Fulton Hospital, Inc
- Wellstreet of Georgia PC
- Wellview Counseling LLC
All providers in Roswell, GA · Family Medicine 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 Feb 18, 2015. 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.