MEDICARE: LEGACY PODIATRY GROUP INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	213ES0131X	Foot Surgery Podiatrist	25MD00245100	NJ

General Provider Information

NPI Number	:	1770512493
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LEGACY PODIATRY GROUP INC

Provider Business Mailing Address
First Line	:	2013 BEVERLY ROAD
Second Line	:
City	:	BURLINGTON
State	:	NJ
Zip	:	08016-0115
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	131 MADISON AVE
Second Line	:	SUITE D
City	:	MOUNT HOLLY
State	:	NJ
Zip	:	08060-2043
Country	:	US
Telephone Number	:	609-267-2700
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. ETHEL MARIA WRIGHT
Credential	:	D.P.M.
Telephone Number	:	610-613-3035

Provider Enumeration Date	:	07/03/2006
Last Update Date	:	11/19/2007

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