Healthcare Provider Details

I. General information

NPI: 1104566165
Provider Name (Legal Business Name): MARIA LY MD/PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/29/2022
Last Update Date: 06/21/2023
Certification Date: 06/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 BARNES JEW HOSP PLZ
SAINT LOUIS MO
63110-1003
US

IV. Provider business mailing address

660 S EUCLID AVE
SAINT LOUIS MO
63110-1010
US

V. Phone/Fax

Practice location:
  • Phone: 314-747-3000
  • Fax:
Mailing address:
  • Phone:
  • 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 Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number2023015976
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: