Basic Information
| Provider Information | |||||||||
| NPI: | 1528103025 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RELIANT MEDICAL GROUP, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 630 PLANTATION ST, WOT 12TH FL | ||||||||
| Address2: | ATTN: MEDICAL STAFF SERVICES | ||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 016052038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5083685424 | ||||||||
| FaxNumber: | 5083685530 | ||||||||
| Practice Location | |||||||||
| Address1: | 425 N LAKE AVE | ||||||||
| Address2: | |||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 016052047 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5088520600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2007 | ||||||||
| LastUpdateDate: | 01/30/2012 | ||||||||
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| AuthorizedOfficialLastName: | RICHMAN | ||||||||
| AuthorizedOfficialFirstName: | ROBIN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF MEDICAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 5088520600 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | 103T00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.