Healthcare Provider Details

I. General information

NPI: 1922145291
Provider Name (Legal Business Name): ADAM HALLADAY LACKEY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 05/01/2024
Certification Date: 05/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3577 W 13 MILE RD SUITE 402
ROYAL OAK MI
48073-6710
US

IV. Provider business mailing address

3 EXECUTIVE DR STE 400
SOMERSET NJ
08873-4007
US

V. Phone/Fax

Practice location:
  • Phone: 248-551-9910
  • Fax: 248-551-9912
Mailing address:
  • Phone: 732-369-5994
  • Fax: 732-369-5993

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number25MA10411900
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number257557
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number25MA10411900
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: