Healthcare Provider Details

I. General information

NPI: 1356735401
Provider Name (Legal Business Name): MR. NGOC LY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2015
Last Update Date: 09/29/2020
Certification Date: 09/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

363 HIGHLAND AVE
FALL RIVER MA
02720-3703
US

IV. Provider business mailing address

200 MILL RD STE 180
FAIRHAVEN MA
02719-5255
US

V. Phone/Fax

Practice location:
  • Phone: 508-973-7558
  • Fax: 508-973-7147
Mailing address:
  • Phone: 508-973-2000
  • Fax: 508-973-2001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LC0200X
TaxonomyCritical Care Medicine (Anesthesiology) Physician
License Number282453
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: