Provider Demographics
NPI:1194197442
Name:LEGACY PHYSIATRY GROUP OREGON, LLC
Entity Type:Organization
Organization Name:LEGACY PHYSIATRY GROUP OREGON, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:VIVEK
Authorized Official - Middle Name:
Authorized Official - Last Name:SASTRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-372-1663
Mailing Address - Street 1:850 CENTRAL PKWY E
Mailing Address - Street 2:STE 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:
Practice Address - Street 1:5 CENTERPOINTE DR
Practice Address - Street 2:STE 400
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-8651
Practice Address - Country:US
Practice Address - Phone:972-372-1663
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-27
Last Update Date:2015-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty