MEDICARE: LEGACY CARE ACO LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	207R00000X	Internal Medicine Physician
2	207RG0300X	Geriatric Medicine (Internal Medicine) Physician
3	363L00000X	Nurse Practitioner
4	207QG0300X	Geriatric Medicine (Family Medicine) Physician
5	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1538844857
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LEGACY CARE ACO LLC

Provider Business Mailing Address
First Line	:	PO BOX 830063
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19182-0063
Country	:	US
Telephone Number	:	757-536-2246
Fax Number	:

Provider Business Practice Location Address
First Line	:	1929 ROSSINI DR
Second Line	:
City	:	VIRGINIA BCH
State	:	VA
Zip	:	23454
Country	:	US
Telephone Number	:	757-536-2246
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR REVENUE CYCLE
Name	:	TRACI LOPEZ
Credential	:
Telephone Number	:	757-536-2411

Provider Enumeration Date	:	06/15/2023
Last Update Date	:	01/07/2026

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Directions to “LEGACY CARE ACO LLC ” Practice Location

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