Healthcare Provider Details

I. General information

NPI: 1326743030
Provider Name (Legal Business Name): MARCUS LACKEY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2023
Last Update Date: 09/18/2026
Certification Date: 09/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101B VILLA DRIVE SUITE 226
DAPHNE AL
36526-4653
US

IV. Provider business mailing address

101B VILLA DRIVE SUITE 226
DAPHNE AL
36526-4653
US

V. Phone/Fax

Practice location:
  • Phone: 251-615-0000
  • Fax: 866-433-9000
Mailing address:
  • Phone: 251-615-0000
  • Fax: 866-433-9000

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License NumberMD.50331
License Number StateAL
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD.50331
License Number StateAL
# 4
Primary TaxonomyN
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License NumberMD.50331
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: