Provider Demographics
NPI:1740406438
Name:TEMPLE MEDICAL LLC
Entity Type:Organization
Organization Name:TEMPLE MEDICAL LLC
Other - Org Name:TEMPLEMED HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:LORI
Authorized Official - Middle Name:A
Authorized Official - Last Name:HUDSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-462-1170
Mailing Address - Street 1:503 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:VILLA RICA
Mailing Address - State:GA
Mailing Address - Zip Code:30180-1931
Mailing Address - Country:US
Mailing Address - Phone:805-869-3240
Mailing Address - Fax:770-462-1174
Practice Address - Street 1:503 MAIN ST
Practice Address - Street 2:
Practice Address - City:VILLA RICA
Practice Address - State:GA
Practice Address - Zip Code:30180-1931
Practice Address - Country:US
Practice Address - Phone:770-462-1170
Practice Address - Fax:770-462-1174
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-18
Last Update Date:2019-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN101917-NP207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000805153CMedicaid
GAS64071Medicare UPIN
GA000805153CMedicaid