MEDICARE: HUGH L LACEY MD PC

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	207V00000X	Obstetrics & Gynecology Physician	R6N85	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1760565048	OTHER	MO	INDIVIDUAL NPI

General Provider Information

NPI Number	:	1588982870
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HUGH L LACEY MD PC

Provider Business Mailing Address
First Line	:	PO BOX 2067
Second Line	:
City	:	JOPLIN
State	:	MO
Zip	:	64804-2067
Country	:	US
Telephone Number	:	417-624-2111
Fax Number	:	417-624-1551

Provider Business Practice Location Address
First Line	:	1905 W32ND STREET
Second Line	:	SUITE 306
City	:	JOPLIN
State	:	MO
Zip	:	64804-1512
Country	:	US
Telephone Number	:	417-624-2111
Fax Number	:	417-624-1551

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. HUGH LAKE LACEY
Credential	:	M.D.
Telephone Number	:	417-624-2111

Provider Enumeration Date	:	05/11/2010
Last Update Date	:	02/17/2012

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