Provider Demographics
NPI:1992826705
Name:EXECUTIVE MEDICAL HEALTHCARE SERVICES
Entity Type:Organization
Organization Name:EXECUTIVE MEDICAL HEALTHCARE SERVICES
Other - Org Name:WELLNESS MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR, FAMILY PRACTICE
Authorized Official - Prefix:DR
Authorized Official - First Name:JELUNDER
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:678-479-1234
Mailing Address - Street 1:PO BOX 224
Mailing Address - Street 2:
Mailing Address - City:LOVEJOY
Mailing Address - State:GA
Mailing Address - Zip Code:30250-0224
Mailing Address - Country:US
Mailing Address - Phone:678-479-1234
Mailing Address - Fax:678-479-5678
Practice Address - Street 1:990 BEAR CREEK BLVD
Practice Address - Street 2:SUITE G
Practice Address - City:HAMPTON
Practice Address - State:GA
Practice Address - Zip Code:30228-1864
Practice Address - Country:US
Practice Address - Phone:678-479-1234
Practice Address - Fax:678-479-5678
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-02
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA042544207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA11D1014694OtherCLIA
GA250161583AMedicaid
GA042544OtherMEDICAL LICENSE
GA042544OtherMEDICAL LICENSE
GA11D1014694OtherCLIA