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General NPI Number Information
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NPI Number | 1801800719
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Entity Type | Organization
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Legal Business Name | LEGACY PHYSICIAN GROUP, P.C.
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Dates
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Enumeration Date | 07/28/2006
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Last Update Date | 02/18/2025
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Provider Practice Location Address
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Address Line | 1540 LAKE LANSING RD 102
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City | LANSING
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State | MI
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Zip | 48912-3756
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Country | US
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Telephone | 517-913-3900
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Fax |
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Provider Business Mailing Address
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Address Line | 1540 LAKE LANSING RD STE 203
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City | LANSING
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State | MI
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Zip | 48912-3757
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Country | US
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Telephone | 517-913-6711
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Fax | 517-913-6712
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Authorized Official
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Title or Position | PRESIDENT
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Name | SUSAN THERESE FEDEWA
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Credential | DR
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Telephone | 517-913-6711
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number |
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License Number State |
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