Basic Information
Provider Information | |||||||||
NPI: | 1184600587 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LACKEY | ||||||||
FirstName: | JEFFREY | ||||||||
MiddleName: | S | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 51030 | ||||||||
Address2: |   | ||||||||
City: | MYRTLE BEACH | ||||||||
State: | SC | ||||||||
PostalCode: | 295790018 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8432388660 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 300 SINGLETON RIDGE RD | ||||||||
Address2: |   | ||||||||
City: | CONWAY | ||||||||
State: | SC | ||||||||
PostalCode: | 295269142 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8432388660 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/16/2005 | ||||||||
LastUpdateDate: | 08/08/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 21294 | SC | Y |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0204X | 21294 | SC | N |   | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2085B0100X | 21294 | SC | N |   | Allopathic & Osteopathic Physicians | Radiology | Body Imaging | 2085D0003X | 21294 | SC | N |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Neuroimaging | 2085U0001X | 21294 | SC | N |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Ultrasound | 2085N0700X | 21294 | SC | N |   | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology | 2085N0904X | 21294 | SC | N |   | Allopathic & Osteopathic Physicians | Radiology | Nuclear Radiology | 2085P0229X | 21294 | SC | N |   | Allopathic & Osteopathic Physicians | Radiology | Pediatric Radiology | 2085R0001X | 21294 | SC | N |   | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology | 2085R0205X | 21294 | SC | N |   | Allopathic & Osteopathic Physicians | Radiology | Radiological Physics | 2085R0203X | 21294 | SC | N |   | Allopathic & Osteopathic Physicians | Radiology | Therapeutic Radiology | 207U00000X | 21294 | SC | N |   | Allopathic & Osteopathic Physicians | Nuclear Medicine |   |
No ID Information.