Provider Demographics
NPI:1477878940
Name:LEGACY FAMILY MEDICINE LLC
Entity Type:Organization
Organization Name:LEGACY FAMILY MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:T
Authorized Official - Last Name:HARDY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:407-781-1000
Mailing Address - Street 1:11602 LAKE UNDERHILL RD
Mailing Address - Street 2:SUITE 119
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32825-4458
Mailing Address - Country:US
Mailing Address - Phone:407-781-1000
Mailing Address - Fax:407-781-1001
Practice Address - Street 1:11602 LAKE UNDERHILL RD STE 119
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32825-4460
Practice Address - Country:US
Practice Address - Phone:407-781-1000
Practice Address - Fax:407-781-1001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-29
Last Update Date:2015-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLDA060AMedicare PIN