Provider Demographics
NPI:1477940740
Name:LEGACY PHYSIATRY GROUP PENNSYLVANIA, LLC
Entity Type:Organization
Organization Name:LEGACY PHYSIATRY GROUP PENNSYLVANIA, LLC
Other - Org Name:LEGACY PHYSIATRY GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
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 1:150 MONUMENT RD
Practice Address - Street 2:STE 207
Practice Address - City:BALA CYNWYD
Practice Address - State:PA
Practice Address - Zip Code:19004-1702
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:2015-04-23
Last Update Date:2015-04-23
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