1437681038 NPI number — LEGION THERAPEUTIC GROUP, LLC

Table of content: (NPI 1437681038)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437681038 NPI number — LEGION THERAPEUTIC GROUP, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LEGION THERAPEUTIC GROUP, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1437681038
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/02/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3553 W CHESTER PIKE UNIT 320
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEWTOWN SQUARE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19073-3701
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
844-534-4661
Provider Business Mailing Address Fax Number:
888-226-4103

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14 ELLIOTT AVE
Provider Second Line Business Practice Location Address:
SUITE 9
Provider Business Practice Location Address City Name:
BRYN MAWR
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19010-3412
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
844-534-4661
Provider Business Practice Location Address Fax Number:
888-226-4103
Provider Enumeration Date:
04/02/2017

Additional Information

Authorized Official

Authorized Official Last Name:
GREEN
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
M
Authorized Official Title or Position:
FOUNDER
Authorized Official Telephone Number:
267-595-0588

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  PC008692 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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