NPIMap

Organization Active NPI

Legacy Primary Care PLLC

  • Adult Medicine Physician
  • Grand Forks, ND
National Provider Identifier
1265277115
Registry record updated Jul 1, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Adult Medicine PhysicianTaxonomy code 207QA0505X
Legal business name
LEGACY PRIMARY CARE PLLC
Practice address
2100 S Columbia Rd Ste 114
Grand Forks, ND 58201-5895
Phone
(701) 516-4637
Fax
(877) 651-1381
NPI assigned
Jul 1, 2024
Last updated
Jul 1, 2024By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 1, 2024

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Heidi WilliamsNPI 1851569347
Title
Cred Spec
Phone
(605) 846-8239

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Adult Medicine PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 207QA0505X Primary

Addresses

Primary practice location

2100 S Columbia Rd Ste 114
Grand Forks, ND 58201-5895

Mailing address

19580 Scout LN
Saint Onge, SD 57779-7913

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in ND, SD, WY, MN, AZ5 enrollments

Enrollment records 5

Enrollment IDStateProvider typePAC IDDetails
O20240813001785 ND Part B Supplier - Clinic/Group Practice 5799223491 Receives reassigned benefits from 13 practitioners
Practice locations: Bismarck, ND; Fargo, ND; Grand Forks, ND; Mandan, ND; Minot, ND
O20241120000810 SD Part B Supplier - Clinic/Group Practice 5799223491 Receives reassigned benefits from 5 practitioners
Practice locations: Watertown, SD; Spearfish, SD; Rapid City, SD; Mitchell, SD; Sioux Falls, SD
O20241212000785 WY Part B Supplier - Clinic/Group Practice 5799223491 Receives reassigned benefits from 5 practitioners
Practice locations: Laramie, WY; Casper, WY; Cheyenne, WY
O20260427001041 MN Part B Supplier - Clinic/Group Practice 5799223491 Receives reassigned benefits from 5 practitioners
Practice locations: Baxter, MN; Brainerd, MN; East Grand Forks, MN; Hermantown, MN; Moorhead, MN; Walker, MN
O20260610001150 AZ Part B Supplier - Clinic/Group Practice 5799223491 Receives reassigned benefits from 1 practitioner
Practice locations: Mesa, AZ

National Provider Directory

National Provider Directory

Locations

2812 N Norwalk
Ste 102
Mesa, AZ 85215

Practitioners & affiliated clinicians

Practitioners 60

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 60

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1719792000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1719792000000",
    "number": "1265277115",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "19580 SCOUT LN",
            "city": "SAINT ONGE",
            "state": "SD",
            "postal_code": "577797913"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2100 S COLUMBIA RD STE 114",
            "city": "GRAND FORKS",
            "state": "ND",
            "postal_code": "582015895",
            "telephone_number": "701-516-4637",
            "fax_number": "877-651-1381"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LEGACY PRIMARY CARE PLLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2024-07-01",
        "last_updated": "2024-07-01",
        "certification_date": "2024-07-01",
        "status": "A",
        "authorized_official_last_name": "WILLIAMS",
        "authorized_official_first_name": "HEIDI",
        "authorized_official_title_or_position": "CRED SPEC",
        "authorized_official_telephone_number": "605-846-8239"
    },
    "taxonomies": [
        {
            "code": "207QA0505X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Family Medicine, Adult Medicine",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Grand Forks, ND

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 1, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.