Provider Demographics
NPI:1154720613
Name:RELIANCE MEDICAL GROUP, LLC
Entity type:Organization
Organization Name:RELIANCE MEDICAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JON
Authorized Official - Middle Name:M
Authorized Official - Last Name:REGIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:609-272-0655
Mailing Address - Street 1:22 N FRANKLIN BLVD
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:PLEASANTVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08232-2547
Mailing Address - Country:US
Mailing Address - Phone:609-272-0655
Mailing Address - Fax:609-272-9317
Practice Address - Street 1:1325 BALTIC AVE
Practice Address - Street 2:
Practice Address - City:ATLANTIC CITY
Practice Address - State:NJ
Practice Address - Zip Code:08401-4516
Practice Address - Country:US
Practice Address - Phone:609-441-0723
Practice Address - Fax:609-441-0953
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-20
Last Update Date:2014-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07552100207Q00000X
NJ25MA04388900207R00000X
NJ25MA03906000208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8139504Medicaid
NJ036099Medicare PIN