Provider Demographics
NPI:1851764112
Name:LEGACY ANESTHESIA LLC
Entity Type:Organization
Organization Name:LEGACY ANESTHESIA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:DAGLEY
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:435-671-1254
Mailing Address - Street 1:PO BOX 3750
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84110-3750
Mailing Address - Country:US
Mailing Address - Phone:800-748-4868
Mailing Address - Fax:770-701-6676
Practice Address - Street 1:1485 S HIGHWAY 40
Practice Address - Street 2:
Practice Address - City:HEBER CITY
Practice Address - State:UT
Practice Address - Zip Code:84032-3522
Practice Address - Country:US
Practice Address - Phone:435-654-2500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-09
Last Update Date:2016-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT120505207L00000X
367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
No367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTU000093939Medicare UPIN