Healthcare Provider Details

I. General information

NPI: 1700882602
Provider Name (Legal Business Name): MICHAEL GEORGE LACEY DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2005
Last Update Date: 04/21/2022
Certification Date: 04/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 W 89TH AVE STE W5
MERRILLVILLE IN
46410-7050
US

IV. Provider business mailing address

25 E SCHAUMBURG RD STE 110
SCHAUMBURG IL
60194-3548
US

V. Phone/Fax

Practice location:
  • Phone: 219-662-2279
  • Fax: 855-742-9438
Mailing address:
  • Phone: 847-352-1473
  • Fax: 847-352-1479

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number016005210
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code213EP0504X
TaxonomyPublic Medicine Podiatrist
License Number016005210
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number016005210
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number07001055A
License Number StateIN
# 5
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number016005210
License Number StateIL
# 6
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number016005210
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: