Provider Demographics
NPI:1447755178
Name:LEGACY SPINE AND PAIN, LLC
Entity type:Organization
Organization Name:LEGACY SPINE AND PAIN, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EHSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:ABDESHAHIAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:410-800-4466
Mailing Address - Street 1:10421 MOTOR CITY DR # 342430
Mailing Address - Street 2:
Mailing Address - City:BETHESDA
Mailing Address - State:MD
Mailing Address - Zip Code:20817-9996
Mailing Address - Country:US
Mailing Address - Phone:301-962-4278
Mailing Address - Fax:
Practice Address - Street 1:10421 MOTOR CITY DR # 342430
Practice Address - Street 2:
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20817-9996
Practice Address - Country:US
Practice Address - Phone:301-962-4278
Practice Address - Fax:833-781-1112
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-26
Last Update Date:2020-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty