Provider Demographics
NPI:1528345162
Name:LEGACY INTERNAL MEDICINE LLC
Entity type:Organization
Organization Name:LEGACY INTERNAL MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TINA
Authorized Official - Middle Name:M
Authorized Official - Last Name:BOTELHO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:843-606-9199
Mailing Address - Street 1:550 LONG POINT RD STE 100
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464-8000
Mailing Address - Country:US
Mailing Address - Phone:843-606-9199
Mailing Address - Fax:843-718-2858
Practice Address - Street 1:550 LONG POINT RD STE 100
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-8000
Practice Address - Country:US
Practice Address - Phone:843-606-9199
Practice Address - Fax:843-718-2858
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-10
Last Update Date:2025-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC253442Medicaid
SCAA8570A913Medicare PIN
AA06016795Medicare PIN
AA0601Medicare UPIN
SCA913Medicare UPIN