MEDICARE: RELIANT PROVIDER SERVICES, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner

General Provider Information

NPI Number	:	1629426846
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RELIANT PROVIDER SERVICES, LLC

Provider Business Mailing Address
First Line	:	6860 DALLAS PKWY
Second Line	:	STE 550
City	:	PLANO
State	:	TX
Zip	:	75024-4232
Country	:	US
Telephone Number	:	972-447-9800
Fax Number	:	972-447-9806

Provider Business Practice Location Address
First Line	:	6860 DALLAS PKWY
Second Line	:	STE 550
City	:	PLANO
State	:	TX
Zip	:	75024-4232
Country	:	US
Telephone Number	:	972-447-9800
Fax Number	:	972-447-9806

Authorized Official
Title or Position	:	CEO
Name	:	JOSEPH MCDONOUGH
Credential	:
Telephone Number	:	972-447-9800

Provider Enumeration Date	:	05/27/2016
Last Update Date	:	08/31/2016

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