Basic Information
| Provider Information | |||||||||
| NPI: | 1699903542 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LEGACY PEDIATRICS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 556 SANDHURST DR | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283044426 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9104832646 | ||||||||
| FaxNumber: | 9104839470 | ||||||||
| Practice Location | |||||||||
| Address1: | 556 SANDHURST DR | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283044426 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9104832646 | ||||||||
| FaxNumber: | 9104839470 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2009 | ||||||||
| LastUpdateDate: | 07/12/2013 | ||||||||
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| AuthorizedOfficialLastName: | HODGES | ||||||||
| AuthorizedOfficialFirstName: | ANA | ||||||||
| AuthorizedOfficialMiddleName: | CEIDE | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/PRACTITIONER | ||||||||
| AuthorizedOfficialTelephone: | 9104832646 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 200000824 | NC | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.