MEDICARE: MRS. LACEY DIVELY MOY MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	036129248	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	036.129248	OTHER	IL	MD LICENSE

General Provider Information

NPI Number	:	1013144021
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LACEY DIVELY MOY MD

Provider Business Mailing Address
First Line	:	3220 ATLANTA ST
Second Line	:
City	:	SPRINGFIELD
State	:	IL
Zip	:	62707-8801
Country	:	US
Telephone Number	:	217-588-7400
Fax Number	:	217-588-7439

Provider Business Practice Location Address
First Line	:	3220 ATLANTA ST
Second Line	:
City	:	SPRINGFIELD
State	:	IL
Zip	:	62707-8801
Country	:	US
Telephone Number	:	217-588-7400
Fax Number	:	217-588-7439

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/17/2009
Last Update Date	:	05/16/2023

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