Basic Information
| Provider Information | |||||||||
| NPI: | 1063765600 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RELIANT MEDICAL GROUP, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5 NEPONSET ST | ||||||||
| Address2: | WOT 2ND FL, STE C203 | ||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 016062714 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5088329621 | ||||||||
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| Practice Location | |||||||||
| Address1: | 385 SOUTHBRIDGE ST | ||||||||
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| City: | AUBURN | ||||||||
| State: | MA | ||||||||
| PostalCode: | 015012498 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5088329621 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2012 | ||||||||
| LastUpdateDate: | 11/11/2019 | ||||||||
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| AuthorizedOfficialLastName: | ELSAWY | ||||||||
| AuthorizedOfficialFirstName: | TAREK | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT & CEO | ||||||||
| AuthorizedOfficialTelephone: | 5088520600 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | RELIANT MEDICAL GROUP, INC | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
No ID Information.