Provider Demographics
NPI:1265142038
Name:LEGENT PHYSICIAN GROUP PLLC
Entity type:Organization
Organization Name:LEGENT PHYSICIAN GROUP PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BRAZELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-339-6824
Mailing Address - Street 1:2722 W BITTERS RD STE 125
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78248-1235
Mailing Address - Country:US
Mailing Address - Phone:726-800-6084
Mailing Address - Fax:469-210-1821
Practice Address - Street 1:5330 N LOOP 1604 W STE 102
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78249-4384
Practice Address - Country:US
Practice Address - Phone:210-819-4562
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-01
Last Update Date:2023-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No207RS0010XAllopathic & Osteopathic PhysiciansInternal MedicineSports MedicineGroup - Multi-Specialty
No207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty