Basic Information
| Provider Information | |||||||||
| NPI: | 1154389815 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LACKEY | ||||||||
| FirstName: | KEITH | ||||||||
| MiddleName: | WOODWARD | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 751649 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282751649 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437891620 | ||||||||
| FaxNumber: | 8437242440 | ||||||||
| Practice Location | |||||||||
| Address1: | 615 WESLEY DRIVE | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8432664400 | ||||||||
| FaxNumber: | 8435770455 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2006 | ||||||||
| LastUpdateDate: | 01/25/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 15543 | SC | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 110105130 | 01 | SC | RR MEDICARE | OTHER | 155432 | 05 | SC | MEDICAID | P00754364 | 01 | SC | RAILROAD MC ID-RSFPN | OTHER | 110232037 | 01 | SC | RR MEDICARE | OTHER |