Provider Demographics
NPI:1962014118
Name:RELYMD MEDICAL GROUP GA, LLC
Entity type:Organization
Organization Name:RELYMD MEDICAL GROUP GA, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO/GENERAL COUNSEL
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:CREATORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-932-0928
Mailing Address - Street 1:510 MEADOWMONT VILLAGE CIR STE 323
Mailing Address - Street 2:
Mailing Address - City:CHAPEL HILL
Mailing Address - State:NC
Mailing Address - Zip Code:27517-7584
Mailing Address - Country:US
Mailing Address - Phone:919-932-0928
Mailing Address - Fax:
Practice Address - Street 1:900 OLD ROSWELL LAKES PKWY STE 310
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-8667
Practice Address - Country:US
Practice Address - Phone:919-932-0928
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RELYMD MEDICAL GROUP, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-08-19
Last Update Date:2020-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA20140276OtherGEORGIA SECRETARY OF STATE