Provider Demographics
NPI:1316078769
Name:LEGACY PHYSIATRY GROUP LLC
Entity type:Organization
Organization Name:LEGACY PHYSIATRY GROUP LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/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
Mailing Address - Street 2:SUITE 275
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75074
Mailing Address - Country:US
Mailing Address - Phone:972-881-4688
Mailing Address - Fax:972-668-5401
Practice Address - Street 1:850 CENTRAL PKWY E STE 275
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75074-5542
Practice Address - Country:US
Practice Address - Phone:972-881-4688
Practice Address - Fax:972-668-5401
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2017-10-05
Deactivation Date:2013-07-09
Deactivation Code:
Reactivation Date:2013-07-30
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX203548702Medicaid
TX203548701Medicaid
TXD07564OtherRAILROAD MEDICARE PALMETTO GBA
TXTXB140060Medicare PIN
TXTXB140062Medicare PIN
TXTXB102731Medicare PIN
TX203548701Medicaid
TX00115XMedicare PIN
TXTXB102736Medicare PIN