MEDICARE: LEGION MEDICAL PA

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	163WP0808X	Psychiatric/Mental Health Registered Nurse
2	364SP0808X	Psychiatric/Mental Health Clinical Nurse Specialist
3	363LP0808X	Psychiatric/Mental Health Nurse Practitioner
4	2084P0800X	Psychiatry Physician

General Provider Information

NPI Number	:	1104511039
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LEGION MEDICAL PA

Provider Business Mailing Address
First Line	:	1613 COYOTE RDG
Second Line	:
City	:	CARROLLTON
State	:	TX
Zip	:	75010-3227
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1613 COYOTE RDG
Second Line	:
City	:	CARROLLTON
State	:	TX
Zip	:	75010-3227
Country	:	US
Telephone Number	:	719-680-9398
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. JONATHAN KOLE
Credential	:	MD
Telephone Number	:	773-633-3499

Provider Enumeration Date	:	04/06/2023
Last Update Date	:	04/09/2026

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Directions to “LEGION MEDICAL PA ” Practice Location

Language	Start Address	Practice Location

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