Provider Demographics
NPI:1366838658
Name:LEGACY PHYSIATRY GROUP MISSOURI, LLC
Entity Type:Organization
Organization Name:LEGACY PHYSIATRY GROUP MISSOURI, 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:
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 1:3636 S GEYER RD
Practice Address - Street 2:100
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63127-1237
Practice Address - Country:US
Practice Address - Phone:972-372-1663
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