Healthcare Provider Details

I. General information

NPI: 1447712302
Provider Name (Legal Business Name): ANDREW J LY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/01/2019
Last Update Date: 11/14/2022
Certification Date: 11/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 N LAKE SHORE DR
CHICAGO IL
60657-5640
US

IV. Provider business mailing address

1229 W KELLY ST
ARLINGTON HEIGHTS IL
60004-8432
US

V. Phone/Fax

Practice location:
  • Phone: 773-665-6730
  • Fax:
Mailing address:
  • Phone: 847-899-0819
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036160798
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: