Healthcare Provider Details

I. General information

NPI: 1902929219
Provider Name (Legal Business Name): PHILLIP LIMBAUGH LACKEY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2007
Last Update Date: 07/07/2022
Certification Date: 07/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1540 SPRING VALLEY DR
HUNTINGTON WV
25704-9501
US

IV. Provider business mailing address

PO BOX 2379
ASHLAND KY
41105-2379
US

V. Phone/Fax

Practice location:
  • Phone: 304-429-6741
  • Fax:
Mailing address:
  • Phone: 606-408-6200
  • Fax: 606-408-6212

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number35.113919
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number23570
License Number StateAL
# 3
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number42124
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: