Provider Demographics
NPI:1144616558
Name:LEGACY PHYSIATRY GROUP LOUISIANA, LLC
Entity Type:Organization
Organization Name:LEGACY PHYSIATRY GROUP LOUISIANA, LLC
Other - Org Name:LEGACY PHYSIATRY GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:VIVEK
Authorized Official - Middle Name:
Authorized Official - Last Name:SASTRY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:972-372-1663
Mailing Address - Street 1:850 CENTRAL PKWY E
Mailing Address - Street 2:SUITE 275
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75074-5561
Mailing Address - Country:US
Mailing Address - Phone:972-372-1663
Mailing Address - Fax:972-372-1657
Practice Address - Street 1:301 MAIN ST
Practice Address - Street 2:STE 2200
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70801-1919
Practice Address - Country:US
Practice Address - Phone:225-224-6426
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LEGACY PHYSIATRY GROUP, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-04-13
Last Update Date:2015-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty