| Legacy Medical Llc | |
|
600 S 2nd St Ste 200 Bismarck ND 58504-5729 | |
| (701) 516-4637 | |
| (877) 651-1381 |
| Full Name | Legacy Medical Llc |
|---|---|
| Speciality | Family Medicine |
| Location | 600 S 2nd St Ste 200, Bismarck, North Dakota |
| Authorized Official Name and Position | Jill Wilson (CHIEF OPERATING OFFICER) |
| Authorized Official Contact | 7015164637 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Legacy Medical Llc Po Box 13238 Grand Forks ND 58208-3238 Ph: (701) 516-4637 | Legacy Medical Llc 600 S 2nd St Ste 200 Bismarck ND 58504-5729 Ph: (701) 516-4637 |
| NPI Number | 1619594637 |
|---|---|
| Provider Enumeration Date | 06/26/2020 |
| Last Update Date | 03/03/2023 |
| Medicare PECOS PAC ID | 0648698290 |
|---|---|
| Medicare Enrollment ID | O20200914001248 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1619594637 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 207QA0505X | Family Medicine - Adult Medicine | (* (Not Available)) | Primary |
| Provider Name | Rebecca Kreis |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1164775441 PECOS PAC ID: 9335392232 Enrollment ID: I20121228000308 |
| Provider Name | Cynthia L Wald |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1912498593 PECOS PAC ID: 7719237932 Enrollment ID: I20180910003123 |
| Provider Name | Chelsea Vollmer |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1871154211 PECOS PAC ID: 9739418435 Enrollment ID: I20190905001406 |
| Provider Name | Michelle Jill Rexine |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1598413312 PECOS PAC ID: 4486040946 Enrollment ID: I20220408002035 |
| Provider Name | Kaitlyn Marie Perez |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1740919224 PECOS PAC ID: 4587045885 Enrollment ID: I20220718003080 |
| Provider Name | Mallorie Emory |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1396484952 PECOS PAC ID: 2567843592 Enrollment ID: I20220721001823 |
| Provider Name | Savannah Rose Smith |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1306558739 PECOS PAC ID: 1254797632 Enrollment ID: I20230510002573 |
| Provider Name | Andrea Marie Jorgenson |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1326810177 PECOS PAC ID: 0345692216 Enrollment ID: I20240116002736 |
| Provider Name | Russell James Niffenegger |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1659154706 PECOS PAC ID: 9931543626 Enrollment ID: I20240221002623 |
| Provider Name | Tiffany Lynn Rhein |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1215792973 PECOS PAC ID: 8527409721 Enrollment ID: I20240517001971 |
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