MEDICARE: DR ROY LACEY LTD

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	1487638847	OTHER	IL	NPI
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1598991325
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DR ROY LACEY LTD

Provider Business Mailing 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	:	773-778-5343

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	:	773-778-5343

Authorized Official
Title or Position	:	OWNER
Name	:	DR. ROY LACEY
Credential	:	D.O.
Telephone Number	:	773-778-1950

Provider Enumeration Date	:	06/08/2009
Last Update Date	:	06/08/2009

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Directions to “DR ROY LACEY LTD ” Practice Location

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