Basic Information
| Provider Information | |||||||||
| NPI: | 1902929219 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LACKEY | ||||||||
| FirstName: | PHILLIP | ||||||||
| MiddleName: | LIMBAUGH | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2379 | ||||||||
| Address2: | |||||||||
| City: | ASHLAND | ||||||||
| State: | KY | ||||||||
| PostalCode: | 411052379 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6064086200 | ||||||||
| FaxNumber: | 6064086212 | ||||||||
| Practice Location | |||||||||
| Address1: | 1540 SPRING VALLEY DR | ||||||||
| Address2: | |||||||||
| City: | HUNTINGTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 257049501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3044296741 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2007 | ||||||||
| LastUpdateDate: | 07/07/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0122X | 35.113919 | OH | N | Allopathic & Osteopathic Physicians | Surgery | Plastic and Reconstructive Surgery | 2086S0122X | 23570 | AL | N | Allopathic & Osteopathic Physicians | Surgery | Plastic and Reconstructive Surgery | 2086S0122X | 42124 | KY | Y | Allopathic & Osteopathic Physicians | Surgery | Plastic and Reconstructive Surgery |
ID Information
| ID | Type | State | Issuer | Description | 000000568865 | 01 | KY | ANTHEM | OTHER | 2853050 | 05 | OH | MEDICAID | 7100048660 | 05 | KY | MEDICAID |