MEDICARE: LEGACY PHYSIATRY GROUP OHIO, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	207R00000X	Internal Medicine Physician
2	363A00000X	Physician Assistant
3	363L00000X	Nurse Practitioner
4	208100000X	Physical Medicine & Rehabilitation Physician

General Provider Information

NPI Number	:	1659768927
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LEGACY PHYSIATRY GROUP OHIO, LLC

Provider Business Mailing Address
First Line	:	850 CENTRAL PKWY E
Second Line	:	SUITE 275
City	:	PLANO
State	:	TX
Zip	:	75074-5561
Country	:	US
Telephone Number	:	972-372-1663
Fax Number	:

Provider Business Practice Location Address
First Line	:	6100 OAK TREE BLVD
Second Line	:	STE 200
City	:	INDEPENDENCE
State	:	OH
Zip	:	44131-2544
Country	:	US
Telephone Number	:	972-372-1663
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT/CEO
Name	:	VIVEK SASTRY
Credential	:	DO
Telephone Number	:	972-372-1663

Provider Enumeration Date	:	04/23/2015
Last Update Date	:	04/23/2015

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