MEDICARE: REGINALD BRUCE LEGROW MD

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	208000000X	Pediatrics Physician	G1944	TX
2	207Q00000X	Family Medicine Physician	G1944	TX
3	208D00000X	General Practice Physician	G1944	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1790778819
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	REGINALD BRUCE LEGROW MD

Provider Business Mailing Address
First Line	:	404 N KAUFMAN ST
Second Line	:
City	:	LINDEN
State	:	TX
Zip	:	75563-5234
Country	:	US
Telephone Number	:	903-756-5581
Fax Number	:	903-756-5005

Provider Business Practice Location Address
First Line	:	402 N KAUFMAN ST
Second Line	:
City	:	LINDEN
State	:	TX
Zip	:	75563-5234
Country	:	US
Telephone Number	:	903-756-5581
Fax Number	:	903-756-5005

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/24/2005
Last Update Date	:	09/23/2013

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