Provider Demographics
NPI:1164841516
Name:STELLA MEDICAL CENTER
Entity type:Organization
Organization Name:STELLA MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CAROLINE
Authorized Official - Middle Name:
Authorized Official - Last Name:ANAELE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-855-2308
Mailing Address - Street 1:2121 FAIRBURN RD STE B
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30135-1029
Mailing Address - Country:US
Mailing Address - Phone:770-855-2308
Mailing Address - Fax:
Practice Address - Street 1:2121 FAIRBURN RD STE B
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30135-1029
Practice Address - Country:US
Practice Address - Phone:770-855-2308
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-14
Last Update Date:2014-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN135346363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA456441108EMedicaid