Provider Demographics
NPI:1659579688
Name:KEITH K LY, DO, P.S.
Entity Type:Organization
Organization Name:KEITH K LY, DO, P.S.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:K
Authorized Official - Last Name:LY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:425-673-8000
Mailing Address - Street 1:6007 244TH ST SW # B
Mailing Address - Street 2:
Mailing Address - City:MOUNTLAKE TERRACE
Mailing Address - State:WA
Mailing Address - Zip Code:98043-5400
Mailing Address - Country:US
Mailing Address - Phone:425-673-8000
Mailing Address - Fax:425-673-9000
Practice Address - Street 1:6007 244TH ST SW # B
Practice Address - Street 2:
Practice Address - City:MOUNTLAKE TERRACE
Practice Address - State:WA
Practice Address - Zip Code:98043-5400
Practice Address - Country:US
Practice Address - Phone:425-673-8000
Practice Address - Fax:425-673-9000
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-11
Last Update Date:2007-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP00001670207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1124254Medicaid
WA1124254Medicaid
G8866814Medicare PIN