Healthcare Provider Details

I. General information

NPI: 1154810901
Provider Name (Legal Business Name): RELIANT MD GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2018
Last Update Date: 05/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19450 DEERFIELD AVE STE 325
LEESBURG VA
20176-8503
US

IV. Provider business mailing address

ATTN. LORI GRIMM 20349 MEDALIST DRIVE
ASHBURN VA
20147
US

V. Phone/Fax

Practice location:
  • Phone: 703-994-6655
  • Fax: 571-291-2752
Mailing address:
  • Phone: 703-994-6655
  • Fax: 571-291-2752

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number0101254080
License Number StateVA

VIII. Authorized Official

Name: DR. SUMAN MANCHIREDDY
Title or Position: OWNER/MEDICAL DIRECTOR
Credential: MD
Phone: 703-994-6655