MEDICARE: ELIJAH AUSTIN LACKEY MD

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	390200000X	Student in an Organized Health Care Education/Training Program
2	2084N0400X	Neurology Physician	2022-00049	CO

General Provider Information

NPI Number	:	1821594219
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELIJAH AUSTIN LACKEY MD

Provider Business Mailing Address
First Line	:	2121 E HARMONY RD UNIT 180
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80528-3401
Country	:	US
Telephone Number	:	970-226-6111
Fax Number	:	970-226-6707

Provider Business Practice Location Address
First Line	:	2121 E HARMONY RD
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80528-3400
Country	:	US
Telephone Number	:	970-226-6111
Fax Number	:	970-226-6707

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

Provider Enumeration Date	:	04/04/2018
Last Update Date	:	05/26/2026

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