Provider Demographics
NPI:1942801600
Name:LEGACY ORTHOPAEDICS
Entity Type:Organization
Organization Name:LEGACY ORTHOPAEDICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:D
Authorized Official - Last Name:RILEY
Authorized Official - Suffix:IV
Authorized Official - Credentials:MD
Authorized Official - Phone:786-845-6645
Mailing Address - Street 1:650 NE 32ND ST UNIT 3003
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33137-5260
Mailing Address - Country:US
Mailing Address - Phone:215-919-0419
Mailing Address - Fax:215-330-4808
Practice Address - Street 1:7000 SW 62ND AVE STE 330
Practice Address - Street 2:
Practice Address - City:SOUTH MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33143-4717
Practice Address - Country:US
Practice Address - Phone:786-238-7402
Practice Address - Fax:215-330-4808
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-07
Last Update Date:2023-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL117862500Medicaid