Provider Demographics
NPI:1558780379
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:
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 1:1601 TILTON RD
Practice Address - Street 2:
Practice Address - City:NORTHFIELD
Practice Address - State:NJ
Practice Address - Zip Code:08225-1877
Practice Address - Country:US
Practice Address - Phone:609-272-0655
Practice Address - Fax:609-272-9317
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-09
Last Update Date:2014-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07552100207Q00000X
NJ25MA03856300207V00000X
NJ25MD00197100213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8139504Medicaid
NJ036099Medicare PIN