MEDICARE: DR. PETER N. LY DPM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	213ES0131X	Foot Surgery Podiatrist	E3804	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1447254396
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PETER N. LY DPM

Provider Business Mailing Address
First Line	:	7717 N. ORANGE PRAIRIE ROAD
Second Line	:
City	:	PEORIA
State	:	IL
Zip	:	61615
Country	:	US
Telephone Number	:	619-518-1506
Fax Number	:	309-589-6994

Provider Business Practice Location Address
First Line	:	7717 N. ORANGE PRAIRIE ROAD
Second Line	:
City	:	PEORIA
State	:	IL
Zip	:	61615
Country	:	US
Telephone Number	:	619-518-1506
Fax Number	:	309-589-6994

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/09/2005
Last Update Date	:	03/27/2013

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