Provider Demographics
NPI:1154389815
Name:LACKEY, KEITH WOODWARD (MD)
Entity type:Individual
Prefix:DR
First Name:KEITH
Middle Name:WOODWARD
Last Name:LACKEY
Suffix:
Gender:
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 751649
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1649
Mailing Address - Country:US
Mailing Address - Phone:888-472-0043
Mailing Address - Fax:843-724-2440
Practice Address - Street 1:615 WESLEY DRIVE
Practice Address - Street 2:SUITE 300
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407
Practice Address - Country:US
Practice Address - Phone:843-266-4400
Practice Address - Fax:843-577-0455
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2025-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC15543207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC110232037OtherRR MEDICARE
SC110105130OtherRR MEDICARE
SCP00754364OtherRAILROAD MC ID-RSFPN
SC155432Medicaid
SC1497874424Medicare PIN
SC1235180571Medicare PIN
SCF757496795Medicare PIN
SC110105130OtherRR MEDICARE
SCF75749Medicare UPIN
SC49436795Medicare ID - Type Unspecified
SCF757494943Medicare PIN