Legacy Medical, LLC

Primary specialty

Internal Medicine PhysicianTaxonomy code 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

Last updated

Oct 8, 2022By the provider in NPPES

Organization subpart

No

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

Authorized official

Name

Dr. Colette Devona Bullock, DONPI 1164612370

Title

Ceo

Phone

(678) 765-7147

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in GA

Enrollment records 1

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

CLIA laboratory certificates

Locations

Practitioners 1

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.

• Colette Devona Bullock, DO

  • Internal Medicine Physician
  • Sugar Hill, GA
  • NPI 1164612370

  Single Specialty

  Medicare reassignment NPD Authorized official

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

{
    "created_epoch": "1549324800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1665187200000",
    "number": "1750846648",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "5422 CUMMING HWY STE 104",
            "city": "SUGAR HILL",
            "state": "GA",
            "postal_code": "305187027",
            "telephone_number": "678-765-7147",
            "fax_number": "877-991-5350"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "5422 CUMMING HWY STE 104",
            "city": "SUGAR HILL",
            "state": "GA",
            "postal_code": "305187027",
            "telephone_number": "678-765-7147",
            "fax_number": "877-991-5350"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LEGACY MEDICAL, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2019-02-05",
        "last_updated": "2022-10-08",
        "certification_date": "2022-10-08",
        "status": "A",
        "authorized_official_last_name": "BULLOCK",
        "authorized_official_first_name": "COLETTE",
        "authorized_official_middle_name": "DEVONA",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "678-765-7147",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "DO"
    },
    "taxonomies": [
        {
            "code": "207R00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Internal Medicine",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Millicent Lampa, RD
• Kristy Williams Larson, PHARMD
• Kimberly Loan Le, NP
• Hallye S. Lee, MS, LPC, NCC
• Jennifer Faith Lee, PT
• Fred J Leydecker III, D.D.S.
• Life Talk Counseling, LLC
• Richard John Liotta, D.O
• Lisa B Ellis, LLC
• Little Cloud Climbers ABA Inc.

• Internal Medicine Physician in Sugar Hill, GA
• Providers in Sugar Hill, GA by specialty
• Internal Medicine Physician in Georgia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 8, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• Medicare Care Compare (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.