NPIMap

Individual provider Active NPI

Charles Warren Lackey, MD

  • Family Medicine Physician
  • Leadville, CO
National Provider Identifier
1144226291
Registry record updated Mar 2, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
19438 Issued in CO
Practice address
822 W 4TH St
Leadville, CO 80461-3861
Phone
(719) 486-1264
NPI assigned
Jun 23, 2005
Last updated
Mar 2, 2023By the provider in NPPES
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Mar 2, 2023

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X 19438 CO Primary

Addresses

Primary practice location

822 W 4TH St
Leadville, CO 80461-3861

Mailing address

822 W 4TH St
Leadville, CO 80461-3861
Phone (719) 486-1264

Other practice location 1

360 Peak One Dr Ste 100
Frisco, CO 80443-5948
Phone (970) 668-4040

Other identifiers 1

IdentifierTypeStateIssuer
01194380MedicaidCO

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in CO
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20051014000818 CO Practitioner - Emergency MedicinePractitioner - Family Practice 0143246579 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Emergency Medicine
Education
Other, 1974
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
Marillac Clinic, Inc.Group PAC ID 1052634748, 19 clinicians

Practice addresses (Care Compare)

87 Merchant Dr
Montrose, CO 81401-3015
Phone (970) 200-1600

Hospital & facility affiliations

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Medicine

State licenses

LicenseStateTypeSpecialty
19438COMDProfessional Counselor

Practice roles

OrganizationSpecialtyStatusNew patients
Marillac Clinic, Inc. Dba Primehealth Family Medicine CurrentSince Sep 20, 2025 Accepting new patients
NPI 1710760343 CurrentSince Sep 20, 2025 Accepting new patients
Apex Emergency Group, Inc Emergency Medicine Past Accepting new patients
High Country Health Care PC Family Medicine Past Accepting new patients
Ozarks Medical Center Family Medicine Past Accepting new patients

Locations

87 Merchant Dr
Montrose, CO 81401
Phone (970) 252-8896

Interoperability endpoints

  • Direct secure messaging: clackey683475@direct.ochin.org

Organizations & group practices 4

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

Hospital & facility affiliations 4

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1119484800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1677715200000",
    "number": "1144226291",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "822 W 4TH ST",
            "city": "LEADVILLE",
            "state": "CO",
            "postal_code": "804613861",
            "telephone_number": "719-486-1264"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "822 W 4TH ST",
            "city": "LEADVILLE",
            "state": "CO",
            "postal_code": "804613861",
            "telephone_number": "719-486-1264"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "360 Peak One Dr Ste 100",
            "address_purpose": "LOCATION",
            "city": "Frisco",
            "state": "CO",
            "postal_code": "804435948",
            "country_code": "US",
            "telephone_number": "970-668-4040",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "LACKEY",
        "first_name": "CHARLES",
        "middle_name": "WARREN",
        "credential": "MD",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2005-06-23",
        "last_updated": "2023-03-02",
        "certification_date": "2023-03-02",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "CO",
            "license": "19438",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "01194380",
            "state": "CO"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Leadville, CO

Sources for this page

Verify at the official NPI Registry.