MEDICARE: DR. ROY LACEY D.O.

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	036055042	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1487638847
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ROY LACEY D.O.

Provider Business Mailing Address
First Line	:	20657 PROMETHIAN WAY
Second Line	:
City	:	OLYMPIA FIELDS
State	:	IL
Zip	:	60461-1517
Country	:	US
Telephone Number	:	708-748-8111
Fax Number	:

Provider Business Practice Location Address
First Line	:	8058 S WESTERN AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60620-5936
Country	:	US
Telephone Number	:	773-778-1950
Fax Number	:	773-778-1866

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

Provider Enumeration Date	:	11/30/2005
Last Update Date	:	02/12/2010

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