Provider Demographics
NPI:1649956970
Name:HYDE, REILLY MORGAN
Entity type:Individual
Prefix:
First Name:REILLY
Middle Name:MORGAN
Last Name:HYDE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:811 BEAR CREEK RD
Mailing Address - Street 2:
Mailing Address - City:MORELAND
Mailing Address - State:GA
Mailing Address - Zip Code:30259-2939
Mailing Address - Country:US
Mailing Address - Phone:770-630-3084
Mailing Address - Fax:
Practice Address - Street 1:1716 9TH AVE S
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35233-1124
Practice Address - Country:US
Practice Address - Phone:205-975-4237
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-22
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
GA12151363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant