Wellstar Medical Group, LLC
Organization Active NPI Pediatrics Physician · Marietta, GA
NPI 1992001952 · NPPES record last updated Nov 18, 2013
Key facts
- NPI
- 1992001952
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Pediatrics Physician 208000000X
- Legal business name
- WELLSTAR MEDICAL GROUP, LLC
- Practice address
- 760 Kennesaw Ave NW
Marietta, GA 30060-6909 - Phone
- (770) 427-0183
- Fax
- (770) 427-0788
- NPI assigned
- Feb 8, 2011
- 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) 12
Practitioners 29
-
Anthony Robert Ambrose, PA-C
-
Cory C Butzon, MD
-
Attri Datta, M.D.
-
Nicholas A. Deangelo, D.O.
-
Cesar A Egoavil, M.D.
-
Janai Lashana Gibson, PA-C
-
Christopher Mark Hall, PA - C
-
Caroline Kamal Abdelmessih Hana, MD, MSC
-
Michael Hardee, MD
-
William Dean Martin, M.D.
-
Elizabeth K Massey, P.A.
-
Vimala P Nair, MD
-
Hitendra Patel, MD
-
Nina Prata, N.P.
-
Tiffany Bentley Smith, AGACNP
-
Felix N Dunkwu, 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
4900 Ivey Rd NW
Bldg 1300
Acworth, GA 30101
6043 Prestley Mill Rd
Ste D
Douglasville, GA 30134
Phone (770) 739-9555
3747 Roswell Rd
Ste 201
Marietta, GA 30062
Phone (470) 956-1590
4441 Atlanta Rd SE
Ste 201
Smyrna, GA 30080
Phone (470) 956-4180
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Pediatrics Physician |
208000000X | GA | Yes |
Addresses
Primary practice location
760 Kennesaw Ave NW
Marietta, GA 30060-6909
Mailing address
760 Kennesaw Ave NW
Marietta, GA 30060-6909
Phone (770) 427-0183
Other names
- WellStar KenMar Pediatrics
Other providers in Marietta, GA
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- Wellstar Medical Specialist 2LLC
- Wellstar Neuropsychology, LLC
- Wellstar Neurosurgery Services, LLC Dba Wellstar Neurosurgery
- Wellstar North Cobb Women'S Health 2 LLC
All providers in Marietta, GA · Pediatrics 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 Nov 18, 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.