MEDICARE: DR. THOMAS KEVIN LACKEY

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	207L00000X	Anesthesiology Physician	21928	AL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	051502368	OTHER	AL	BLUE CROSS BLUE SHIELD
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1720060247
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. THOMAS KEVIN LACKEY

Provider Business Mailing Address
First Line	:	3804 RAINBOW DR
Second Line	:
City	:	RAINBOW CITY
State	:	AL
Zip	:	35906-3051
Country	:	US
Telephone Number	:	256-952-2200
Fax Number	:	256-952-2202

Provider Business Practice Location Address
First Line	:	3804 RAINBOW DR
Second Line	:
City	:	RAINBOW CITY
State	:	AL
Zip	:	35906
Country	:	US
Telephone Number	:	256-952-2200
Fax Number	:	256-952-2202

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/18/2005
Last Update Date	:	06/21/2018

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