Healthcare Provider Details

I. General information

NPI: 1669869939
Provider Name (Legal Business Name): LEGACY PHYSIATRY GROUP MARYLAND, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2015
Last Update Date: 10/27/2023
Certification Date: 10/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9711 WASHINGTONIAN BLVD STE 550
GAITHERSBURG MD
20878-5789
US

IV. Provider business mailing address

850 CENTRAL PKWY E STE 275
PLANO TX
75074-5542
US

V. Phone/Fax

Practice location:
  • Phone: 972-881-4688
  • Fax: 972-372-1657
Mailing address:
  • Phone: 972-881-4688
  • Fax: 972-372-1657

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MARILYN J MEARON
Title or Position: BILLING MANAGER
Credential:
Phone: 972-881-4688