Healthcare Provider Details

I. General information

NPI: 1891616876
Provider Name (Legal Business Name): BLUEGLOVE PRIMARY CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2026
Last Update Date: 07/23/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

815 PINE MNR
MARIETTA GA
30066-3837
US

IV. Provider business mailing address

815 PINE MNR
MARIETTA GA
30066-3837
US

V. Phone/Fax

Practice location:
  • Phone: 770-405-9320
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. JIEXI LIAO
Title or Position: MANAGING MEMBER
Credential: PHD
Phone: 770-405-9320