Provider Demographics
NPI:1265432876
Name:LACEY, PAUL GRAY (MD)
Entity type:Individual
Prefix:DR
First Name:PAUL
Middle Name:GRAY
Last Name:LACEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:PAUL
Other - Middle Name:GRAY
Other - Last Name:LACEY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:423 N 21ST ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CAMP HILL
Mailing Address - State:PA
Mailing Address - Zip Code:17011-2207
Mailing Address - Country:US
Mailing Address - Phone:717-238-3111
Mailing Address - Fax:717-238-1896
Practice Address - Street 1:4387 STURBRIDGE DR
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17110-3673
Practice Address - Country:US
Practice Address - Phone:717-238-3111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-26
Last Update Date:2020-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD 044099 L207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA50058922OtherCAPITAL BLUE CROSS
PA739366OtherHIGHMARK BLUE SHIELD
PAP00318652OtherRAILROAD MEDICARE
PA4363687OtherAETNA US HEALTHCARE
PAF53848OtherHEALTHAMERICA
PA0014076520002Medicaid
PAF53848OtherHEALTHAMERICA