Provider Demographics
NPI:1841967064
Name:LEGACY PHYSIATRY GROUP NORTH CAROLINA
Entity type:Organization
Organization Name:LEGACY PHYSIATRY GROUP NORTH CAROLINA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:VENKATESH
Authorized Official - Middle Name:
Authorized Official - Last Name:LAKSHMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:972-881-4688
Mailing Address - Street 1:850 CENTRAL PKWY E STE 275
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75074-5542
Mailing Address - Country:US
Mailing Address - Phone:972-881-4688
Mailing Address - Fax:
Practice Address - Street 1:3520 AIRPORT BLVD NW STE D
Practice Address - Street 2:
Practice Address - City:WILSON
Practice Address - State:NC
Practice Address - Zip Code:27896-8674
Practice Address - Country:US
Practice Address - Phone:855-655-7777
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-25
Last Update Date:2022-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty