Provider Demographics
NPI:1598991325
Name:DR ROY LACEY LTD
Entity Type:Organization
Organization Name:DR ROY LACEY LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROY
Authorized Official - Middle Name:
Authorized Official - Last Name:LACEY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:773-778-1950
Mailing Address - Street 1:8058 S WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60620-5936
Mailing Address - Country:US
Mailing Address - Phone:773-778-1950
Mailing Address - Fax:773-778-5343
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:773-778-5343
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-08
Last Update Date:2009-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036055042207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1487638847OtherNPI
IL036055042Medicaid
ILD13153Medicare UPIN