Healthcare Provider Details

I. General information

NPI: 1114389145
Provider Name (Legal Business Name): LACY SAMUEL HANDSHOE D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/29/2016
Last Update Date: 06/11/2021
Certification Date: 06/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4915 NORTON HEALTHCARE BLVD STE 301
LOUISVILLE KY
40241-2860
US

IV. Provider business mailing address

9500 EUCLID AVE
CLEVELAND OH
44195-0001
US

V. Phone/Fax

Practice location:
  • Phone: 502-394-6460
  • Fax: 502-394-6465
Mailing address:
  • Phone: 216-445-3616
  • Fax: 216-636-2175

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 Code2084N0400X
TaxonomyNeurology Physician
License Number04950
License Number StateKY
# 3
Primary TaxonomyY
Taxonomy Code2084V0102X
TaxonomyVascular Neurology Physician
License Number04950
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: