Healthcare Provider Details

I. General information

NPI: 1780147108
Provider Name (Legal Business Name): LEGACY HEALTH PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2019
Last Update Date: 04/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3049 SENNA DR
MATTHEWS NC
28105-6727
US

IV. Provider business mailing address

3049 SENNA DR
MATTHEWS NC
28105-6727
US

V. Phone/Fax

Practice location:
  • Phone: 980-339-5155
  • Fax: 980-216-8522
Mailing address:
  • Phone: 980-339-5155
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. BRIAN JERBY
Title or Position: LEAD PHYSICIAN
Credential: MD
Phone: 980-339-5155