MEDICARE: DR JOHN LACKEY INC

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
1	207W00000X	Ophthalmology Physician	736 WV	WV

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	DG9055	OTHER	WV	MEDICARE RAILROAD GROUP

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1205951605	OTHER	WV	NPI - GROUP
3	1329809	OTHER	WV	UMWA FUNDS
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1205951605
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DR JOHN LACKEY INC

Provider Business Mailing Address
First Line	:	702 PROFESSIONAL PARK DR
Second Line	:	SUITE 102
City	:	SUMMERSVILLE
State	:	WV
Zip	:	26651-2018
Country	:	US
Telephone Number	:	304-872-6433
Fax Number	:	304-872-6562

Provider Business Practice Location Address
First Line	:	702 PROFESSIONAL PARK DR
Second Line	:	SUITE 102
City	:	SUMMERSVILLE
State	:	WV
Zip	:	26651-2018
Country	:	US
Telephone Number	:	304-872-6433
Fax Number	:	304-872-6562

Authorized Official
Title or Position	:	OWNER PHYSICIAN
Name	:	JOHN K LACKEY
Credential	:	D.O.
Telephone Number	:	304-872-6433

Provider Enumeration Date	:	03/21/2007
Last Update Date	:	02/21/2011

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Directions to “DR JOHN LACKEY INC ” Practice Location

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