Provider Demographics
NPI:1275914483
Name:LEGACY PHYSIATRY GROUP WISCONSIN, LLC
Entity Type:Organization
Organization Name:LEGACY PHYSIATRY GROUP WISCONSIN, 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:
Practice Address - Street 1:200 S EXECUTIVE DR
Practice Address - Street 2:SUITE 101
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-4216
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:2015-06-12
Last Update Date:2015-06-12
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