Provider Demographics
NPI:1649225020
Name:LACY, JEROME P (MD)
Entity Type:Individual
Prefix:MR
First Name:JEROME
Middle Name:P
Last Name:LACY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 950232
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40295-0232
Mailing Address - Country:US
Mailing Address - Phone:502-891-8300
Mailing Address - Fax:502-891-8338
Practice Address - Street 1:6420 DUTCHMANS PKWY
Practice Address - Street 2:SUITE 200
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40205-3372
Practice Address - Country:US
Practice Address - Phone:502-891-8300
Practice Address - Fax:502-891-8338
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2015-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY15898207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100388580AMedicaid
KY50032166OtherPASSPORT- CTS
KY000000044915OtherANTHEM PIN
IN100388580FMedicaid
KY1056116OtherPASSPORT
KY2433840000OtherPASSPORT ADVANTAGE PIN
KY64158983Medicaid
KY4012633OtherAETNA- CTS
KY64158983Medicaid
KY00059009Medicare PIN
KY2433840000OtherPASSPORT ADVANTAGE PIN
KY0558212Medicare ID - Type Unspecified
KY1271808Medicare ID - Type Unspecified
KY0368212Medicare ID - Type Unspecified
KY0558402Medicare ID - Type Unspecified
KY060049843Medicare PIN
KY4012633OtherAETNA- CTS
KYP400038660Medicare PIN