Provider Demographics
NPI:1801838198
Name:RELIANT IMMEDIATE CARE MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:RELIANT IMMEDIATE CARE MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MAX
Authorized Official - Middle Name:F
Authorized Official - Last Name:LEBOW
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-215-6020
Mailing Address - Street 1:9601 S SEPULVEDA BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-5203
Mailing Address - Country:US
Mailing Address - Phone:310-215-6020
Mailing Address - Fax:310-641-3521
Practice Address - Street 1:9601 S SEPULVEDA BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90045-5203
Practice Address - Country:US
Practice Address - Phone:310-215-6020
Practice Address - Fax:310-641-3521
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0093640Medicaid
CAW19038Medicare PIN