Active NPI
Legacy Primary Care PLLC
- Adult Medicine Physician
- Grand Forks, ND
National Provider Identifier
1265277115
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Adult Medicine Physician
- 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
- Organization subpart
- No
Authorized official
NPPES NPI Registry- Name
- Heidi Williams
- 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.
Practitioners 60
Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.
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Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in ND, SD, WY, MN, AZ
Medicare enrollment records 5
Medicare enrollment files| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| 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 DirectoryLocations
2812 N Norwalk
Ste 102
Mesa, AZ 85215
2100 S Columbia Rd
Ste 114
Grand Forks, ND 58201
Phone (701) 757-2225
2801 39th Ave SE
Mandan, ND 58554
Phone (701) 663-5664
4001 Derby Ln
Rapid City, SD 57701
Phone (605) 716-2466
Specialties & licenses 1
NPPES NPI Registry| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Adult Medicine Physician | 207QA0505X | Primary |
Addresses
NPPES NPI RegistryPrimary practice location
2100 S Columbia Rd Ste 114
Grand Forks, ND 58201-5895
Mailing address
19580 Scout LN
Saint Onge, SD 57779-7913
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format, last updated by the provider on Jul 1, 2024.
{
"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.