Provider Demographics
NPI:1487630448
Name:KNIGHT, LACY A (MD)
Entity type:Individual
Prefix:
First Name:LACY
Middle Name:A
Last Name:KNIGHT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:660 N WESTMORELAND RD
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60045-1659
Mailing Address - Country:US
Mailing Address - Phone:847-535-6150
Mailing Address - Fax:847-535-7801
Practice Address - Street 1:660 N WESTMORELAND RD
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:IL
Practice Address - Zip Code:60045-1659
Practice Address - Country:US
Practice Address - Phone:847-535-6150
Practice Address - Fax:847-535-7801
Is Sole Proprietor?:No
Enumeration Date:2005-12-21
Last Update Date:2014-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36107997207PE0004X
IL036107997207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL36107997Medicaid
ILH79801Medicare UPIN
IL743830002Medicare PIN
IL36107997Medicaid