Provider Demographics
NPI:1487091369
Name:LACEY MEDICAL GROUP, LLC
Entity type:Organization
Organization Name:LACEY MEDICAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANN
Authorized Official - Middle Name:
Authorized Official - Last Name:DIPAOLO
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:609-693-0819
Mailing Address - Street 1:1044 LACEY RD STE 9
Mailing Address - Street 2:
Mailing Address - City:FORKED RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08731-1051
Mailing Address - Country:US
Mailing Address - Phone:609-693-0819
Mailing Address - Fax:
Practice Address - Street 1:1044 LACEY RD STE 9
Practice Address - Street 2:
Practice Address - City:FORKED RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08731-1051
Practice Address - Country:US
Practice Address - Phone:609-693-0819
Practice Address - Fax:609-971-0834
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-31
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB07677400207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0052680Medicaid