Provider Demographics
NPI:1619003886
Name:LEGEND INTERNAL MEDICINE, URGENT CARE & DIAGNOSTIC
Entity Type:Organization
Organization Name:LEGEND INTERNAL MEDICINE, URGENT CARE & DIAGNOSTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:FIDELIS
Authorized Official - Middle Name:K
Authorized Official - Last Name:UNINI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-301-2053
Mailing Address - Street 1:609 HEMPHILL ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-4137
Mailing Address - Country:US
Mailing Address - Phone:817-923-8484
Mailing Address - Fax:817-923-8494
Practice Address - Street 1:609 HEMPHILL ST
Practice Address - Street 2:SUITE 101
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4137
Practice Address - Country:US
Practice Address - Phone:817-923-8484
Practice Address - Fax:817-923-8494
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-24
Last Update Date:2014-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM5959261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care