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NPI Code Detail

MEDICARE: BETTY JANE LACKEY D.O.

MEDICARE: BETTY JANE LACKEY D.O.
Medicare Provider Information

Scope of Practice

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

# Taxonomy Code Taxonomy License Number License Number State
1207QG0300XGeriatric Medicine (Family Medicine) Physician36751SC
2207QH0002XHospice and Palliative Medicine (Family Medicine) Physician36751SC
3390200000XStudent in an Organized Health Care Education/Training Program

Medicare Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
4P01624384OTHERSCRR MEDICARE

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1NPI #OTHERSCBLUE CHOICE
2MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3NPI #OTHERSCTRICARE
5NPI #OTHERSCBLUE CROSS

General Provider Information

NPI Number : 1043448509
Entity Type Code : Individual
Provider Name (Legal Business Name) : BETTY JANE LACKEY D.O.
Provider Business Mailing Address
First Line : 800 N FANT ST
Second Line :
City : ANDERSON
State : SC
Zip : 29621-5708
Country : US
Telephone Number : 864-512-1000
Fax Number :
Provider Business Practice Location Address
First Line : 255 ENTERPRISE BLVD STE 101
Second Line :
City : GREENVILLE
State : SC
Zip : 29615-3530
Country : US
Telephone Number : 864-454-8120
Fax Number : 864-454-8125
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/23/2009
Last Update Date : 08/08/2019

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Directions to “ BETTY JANE LACKEY D.O.” Practice Location

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