Provider Demographics
NPI:1790834752
Name:SUSAN N. LEGACY, MD PLLC
Entity Type:Organization
Organization Name:SUSAN N. LEGACY, MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:N
Authorized Official - Last Name:LEGACY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:802-876-4000
Mailing Address - Street 1:188 ALLEN BROOK LN
Mailing Address - Street 2:
Mailing Address - City:WILLISTON
Mailing Address - State:VT
Mailing Address - Zip Code:05495-9303
Mailing Address - Country:US
Mailing Address - Phone:802-876-4000
Mailing Address - Fax:802-876-4001
Practice Address - Street 1:188 ALLEN BROOK LN
Practice Address - Street 2:
Practice Address - City:WILLISTON
Practice Address - State:VT
Practice Address - Zip Code:05495-9303
Practice Address - Country:US
Practice Address - Phone:802-876-4000
Practice Address - Fax:802-876-4001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1010298Medicaid
VTVN3441Medicare ID - Type UnspecifiedMCRA GROUP