Basic Information
| Provider Information | |||||||||
| NPI: | 1356838494 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LY | ||||||||
| FirstName: | PETER | ||||||||
| MiddleName: | JAMES | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 32010 JEFFERSON AVE | ||||||||
| Address2: | |||||||||
| City: | SAINT CLAIR SHORES | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480821365 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2484625821 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1900 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | FINDLAY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458401216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4194234500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2018 | ||||||||
| LastUpdateDate: | 08/24/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207Q00000X | 4301505003 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.