Healthcare Provider Details

I. General information

NPI: 1194197442
Provider Name (Legal Business Name): LEGACY PHYSIATRY GROUP OREGON, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

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

III. Provider practice location address

5 CENTERPOINTE DR STE 400
LAKE OSWEGO OR
97035-8651
US

IV. Provider business mailing address

850 CENTRAL PKWY E STE 275
PLANO TX
75074-5561
US

V. Phone/Fax

Practice location:
  • Phone: 972-372-1663
  • Fax:
Mailing address:
  • Phone: 972-372-1663
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number StateNULL
# 6
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: VIVEK SASTRY
Title or Position: CEO
Credential:
Phone: 972-372-1663