=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932713658
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LIYUN LIU MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/31/2020
-----------------------------------------------------
Last Update Date | 09/12/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 730 GLYNN ST S
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30214-2050
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-460-3658
-----------------------------------------------------
Fax | 770-460-3657
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 730 GLYNN ST S
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30214-2050
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-460-3658
-----------------------------------------------------
Fax | 770-460-3657
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 95975
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------