| 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 |
|---|---|
| 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 |
|---|---|
| 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 |
|---|---|
| Provider Enumeration Date | 08/27/2012 |
| Last Update Date | 07/25/2019 |
| Medicare PECOS PAC ID | 5193962173 |
|---|---|
| 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 | Collette Palmisano |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1528174216 PECOS PAC ID: 7719970953 Enrollment ID: I20040405001238 |
| Provider Name | Sunit Srivastava |
|---|---|
| Provider Type | Practitioner - Internal Medicine |
| Provider Identifiers | NPI Number: 1881889467 PECOS PAC ID: 6507998846 Enrollment ID: I20100721000864 |
| Provider Name | Maryana Henson |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1417331273 PECOS PAC ID: 1153638606 Enrollment ID: I20150915002973 |
| Provider Name | Brent J Lataille |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1598202814 PECOS PAC ID: 2365726320 Enrollment ID: I20170313000270 |
| Provider Name | Kathryn E Lataille |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1891232823 PECOS PAC ID: 4486915097 Enrollment ID: I20180222001240 |
| Provider Name | Tammy Lin Hieber |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1720599046 PECOS PAC ID: 3476898016 Enrollment ID: I20181228002496 |
| Provider Name | Sharee D Rogers |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1598277824 PECOS PAC ID: 6305179516 Enrollment ID: I20190603002216 |
| Provider Name | Brian A Field |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1013180090 PECOS PAC ID: 0547331381 Enrollment ID: I20191226000967 |
| Provider Name | Amber Nicole Russo |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1154979839 PECOS PAC ID: 2264866284 Enrollment ID: I20191230001111 |
| Provider Name | Sergio Enrique Pedraza |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1366185241 PECOS PAC ID: 1153708870 Enrollment ID: I20220519000407 |
| Provider Name | Tywanna Jaye Montgomery |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1164147187 PECOS PAC ID: 5890163471 Enrollment ID: I20221202000474 |
| Provider Name | Patricia De Lima |
|---|---|
| Provider Type | Practitioner - Internal Medicine |
| Provider Identifiers | NPI Number: 1588105985 PECOS PAC ID: 4183962806 Enrollment ID: I20230915002474 |
| Provider Name | Chelsea Marie Hughes |
|---|---|
| Provider Type | Practitioner - Internal Medicine |
| Provider Identifiers | NPI Number: 1487281697 PECOS PAC ID: 9739536764 Enrollment ID: I20231113001062 |
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