Provider Demographics
NPI:1487638847
Name:LACEY, ROY (DO)
Entity Type:Individual
Prefix:DR
First Name:ROY
Middle Name:
Last Name:LACEY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20657 PROMETHIAN WAY
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA FIELDS
Mailing Address - State:IL
Mailing Address - Zip Code:60461-1517
Mailing Address - Country:US
Mailing Address - Phone:708-748-8111
Mailing Address - Fax:
Practice Address - Street 1:8058 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60620-5936
Practice Address - Country:US
Practice Address - Phone:773-778-1950
Practice Address - Fax:773-778-1866
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-30
Last Update Date:2010-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036055042207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036055042Medicaid
IL493010Medicare PIN