Legacy Medical, LLC – Internal Medicine Physician

Key facts

NPI: 1750846648
Entity type: Organization (NPI type 2)
Primary specialty: Internal Medicine Physician 207R00000X
Legal business name: LEGACY MEDICAL, LLC
Practice address: 5422 Cumming Hwy Ste 104
Sugar Hill, GA 30518-7027
Phone: (678) 765-7147
Fax: (877) 991-5350
NPI assigned: Feb 5, 2019
Organization subpart: No

Authorized official

Name: Dr. Colette Devona Bullock, DO
Title: Ceo
Phone: (678) 765-7147

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

Colette Devona Bullock, DO Internal Medicine Physician · Sugar Hill, GA · NPI 1164612370

Medicare reassignment NPD GA · SINGLE SPECIALTY

Laboratory certificates & supplier records

Name & address match These CMS records do not include an NPI. They are shown here because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA number	Laboratory	Certificate	Expires
11D2208235	Legacy Medical LLC 5422 Cumming Highway NE Suite 104, Sugar Hill, GA 30518	Certificate of waiver	Jan 4, 2027

Medicare participation

Medicare fee-for-service enrollment: Enrolled in GA

Medicare enrollment records

Enrollment ID	State	Provider type	PAC ID	Details
O20200129001441	GA	Part B Supplier - Clinic/Group Practice	9739515404	Receives reassigned benefits from 1 practitioner Practice locations: Sugar Hill, GA

National Provider Directory

Locations

5422 Cumming Hwy
Ste 104
Sugar Hill, GA 30518
Phone (678) 466-9193

Specialties & licenses

Specialty (taxonomy)	Code	License	State	Primary
Internal Medicine Physician Group: 193400000X SINGLE SPECIALTY GROUP	207R00000X			Yes

Addresses

Primary practice location

5422 Cumming Hwy Ste 104
Sugar Hill, GA 30518-7027

Mailing address

5422 Cumming Hwy Ste 104
Sugar Hill, GA 30518-7027
Phone (678) 765-7147

Other providers in Sugar Hill, GA

All providers in Sugar Hill, GA · Internal Medicine Physician in Georgia

Sources for this page

NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Oct 8, 2022. Information in NPPES is self-reported and not verified by CMS.
NUCC Health Care Provider Taxonomy: specialty names.
Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.