Provider Demographics
NPI:1669869939
Name:LEGACY PHYSIATRY GROUP MARYLAND, LLC
Entity type:Organization
Organization Name:LEGACY PHYSIATRY GROUP MARYLAND, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARILYN
Authorized Official - Middle Name:J
Authorized Official - Last Name:MEARON
Authorized Official - Suffix:
Authorized Official - Credentials:
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:972-372-1657
Practice Address - Street 1:9711 WASHINGTONIAN BLVD STE 550
Practice Address - Street 2:
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20878-5789
Practice Address - Country:US
Practice Address - Phone:972-881-4688
Practice Address - Fax:972-372-1657
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-23
Last Update Date:2023-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty