Provider Demographics
NPI:1356838494
Name:LY, PETER JAMES (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:JAMES
Last Name:LY
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 1:32010 JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48082-1365
Mailing Address - Country:US
Mailing Address - Phone:248-462-5821
Mailing Address - Fax:
Practice Address - Street 1:1900 S MAIN ST
Practice Address - Street 2:
Practice Address - City:FINDLAY
Practice Address - State:OH
Practice Address - Zip Code:45840-1216
Practice Address - Country:US
Practice Address - Phone:419-423-4500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-14
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA193415207Q00000X
390200000X
MI4301505003207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program