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General NPI Number Information
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NPI Number | 1891616876
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Entity Type | Organization
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Legal Business Name | BLUEGLOVE PRIMARY CARE LLC
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Dates
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Enumeration Date | 07/23/2026
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Last Update Date | 07/23/2026
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Provider Practice Location Address
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Address Line | 815 PINE MNR
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City | MARIETTA
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State | GA
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Zip | 30066-3837
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Country | US
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Telephone | 770-405-9320
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Fax |
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Provider Business Mailing Address
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Address Line | 815 PINE MNR
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City | MARIETTA
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State | GA
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Zip | 30066-3837
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | MANAGING MEMBER
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Name | DR. JIEXI LIAO
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Credential | PHD
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Telephone | 770-405-9320
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number |
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License Number State |
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