MEDICARE: DR. LACKEY GENE MOODY M.D.

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	C-4126	AR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	53736	OTHER	AR	BLUE CROSS OF AR

General Provider Information

NPI Number	:	1730149741
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LACKEY GENE MOODY M.D.

Provider Business Mailing Address
First Line	:	PO BOX 2335
Second Line	:
City	:	BATESVILLE
State	:	AR
Zip	:	72503-2335
Country	:	US
Telephone Number	:	870-793-6887
Fax Number	:	870-793-8085

Provider Business Practice Location Address
First Line	:	1301 WHITE DR
Second Line	:
City	:	BATESVILLE
State	:	AR
Zip	:	72501-9467
Country	:	US
Telephone Number	:	870-793-6887
Fax Number	:	870-793-8085

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

Provider Enumeration Date	:	03/24/2006
Last Update Date	:	07/08/2007

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