MEDICARE: RELIANCE MEDICAL GROUP - DETROIT

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number State
1	207Q00000X	Family Medicine Physician
2	208000000X	Pediatrics Physician	MI
3	208D00000X	General Practice Physician
4	207R00000X	Internal Medicine Physician	MI

General Provider Information

NPI Number	:	1871847640
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RELIANCE MEDICAL GROUP - DETROIT

Provider Business Mailing Address
First Line	:	6420 FARMINGTON RD
Second Line	:	SUITE 106
City	:	WEST BLOOMFIELD
State	:	MI
Zip	:	48322-2276
Country	:	US
Telephone Number	:	248-203-1282
Fax Number	:	248-203-4148

Provider Business Practice Location Address
First Line	:	6420 FARMINGTON RD
Second Line	:	SUITE 106
City	:	WEST BLOOMFIELD
State	:	MI
Zip	:	48322-2276
Country	:	US
Telephone Number	:	248-203-1282
Fax Number	:	248-203-4148

Authorized Official
Title or Position	:	BILLING/CREDENTIALING MANAGER
Name	:	RENE M WEEKS
Credential	:
Telephone Number	:	248-203-1282

Provider Enumeration Date	:	11/01/2012
Last Update Date	:	11/01/2012

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