Legacy Health Medical Group, Llc | |
3500 Oak Manor Ln # 46 Largo FL 33774-1211 | |
(727) 489-3305 | |
(727) 499-9559 |
Full Name | Legacy Health Medical Group, Llc |
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Speciality | Clinic/Center |
Location | 3500 Oak Manor Ln # 46, Largo, Florida |
Authorized Official Name and Position | Sunit Srivastava (MANAGING MEMBER) |
Authorized Official Contact | 7276441540 |
Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
Mailing Address | Practice Location Address |
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Legacy Health Medical Group, Llc 3500 Oak Manor Ln # 46 Largo FL 33774-1211 Ph: (727) 489-3305 | Legacy Health Medical Group, Llc 3500 Oak Manor Ln # 46 Largo FL 33774-1211 Ph: (727) 489-3305 |
NPI Number | 1881942779 |
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Provider Enumeration Date | 08/27/2012 |
Last Update Date | 07/25/2019 |
Medicare PECOS PAC ID | 5193962173 |
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Medicare Enrollment ID | O20130510000372 |
Identifier | Type | State | Issuer |
---|---|---|---|
1881942779 | NPI | - | NPPES |
ME105069 | Other | FL | MEDICAL LICENSE NUMBER |
Taxonomy | Type | License (State) | Status |
---|---|---|---|
207R00000X | Internal Medicine | ME105069 (Florida) | Secondary |
261QM1300X | Clinic/center - Multi-specialty | (* (Not Available)) | Primary |
Provider Name | Kathryn E Lataille |
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Provider Type | Practitioner - Nurse Practitioner |
Provider Identifiers | NPI Number: 1891232823 PECOS PAC ID: 4486915097 Enrollment ID: I20180222001240 |
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