Provider Demographics
NPI:1043448509
Name:LACKEY, BETTY JANE (DO)
Entity Type:Individual
Prefix:
First Name:BETTY
Middle Name:JANE
Last Name:LACKEY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 N FANT ST
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:SC
Mailing Address - Zip Code:29621-5708
Mailing Address - Country:US
Mailing Address - Phone:864-512-1000
Mailing Address - Fax:
Practice Address - Street 1:255 ENTERPRISE BLVD STE 101
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-3530
Practice Address - Country:US
Practice Address - Phone:864-454-8120
Practice Address - Fax:864-454-8125
Is Sole Proprietor?:No
Enumeration Date:2009-06-23
Last Update Date:2019-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC36751207QG0300X, 207QH0002X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative Medicine
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNPI #OtherBLUE CHOICE
SC367515Medicaid
SCNPI #OtherTRICARE
SCP01624384OtherRR MEDICARE
SCNPI #OtherBLUE CROSS
SCSC45077111Medicare PIN
SCNPI #OtherBLUE CROSS