MEDICARE: DR. JOANNE L. LACEY 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	2085N0700X	Neuroradiology Physician	2004001646	MO
2	2085R0202X	Diagnostic Radiology Physician	2004001646	MO

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	:	1508950841
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOANNE L. LACEY MD

Provider Business Mailing Address
First Line	:	108 FRONTENAC FRST
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63131-3218
Country	:	US
Telephone Number	:	314-497-2368
Fax Number	:

Provider Business Practice Location Address
First Line	:	108 FRONTENAC FRST
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63131-3218
Country	:	US
Telephone Number	:	314-497-2368
Fax Number	:

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

Provider Enumeration Date	:	10/03/2006
Last Update Date	:	11/09/2022

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