Provider Demographics
NPI:1255375614
Name:LEGALLEY, THOMAS DALE (MD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:DALE
Last Name:LEGALLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1414 WEST FAIR AVENUE
Mailing Address - Street 2:SUITE 334
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855
Mailing Address - Country:US
Mailing Address - Phone:906-225-3870
Mailing Address - Fax:906-225-4861
Practice Address - Street 1:1414 WEST FAIR AVENUE
Practice Address - Street 2:SUITE 334
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855
Practice Address - Country:US
Practice Address - Phone:906-225-3870
Practice Address - Fax:906-225-4861
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2008-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301038201207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
060009221OtherRAILROAD MEDICARE
WI34965800Medicaid
MI1391202Medicaid
MI0605206331OtherBLUE CROSS BLUE SHIELD
N85390004Medicare PIN
MI0605206331OtherBLUE CROSS BLUE SHIELD
0C16002035Medicare PIN