Healthcare Provider Details

I. General information

NPI: 1104558170
Provider Name (Legal Business Name): KENNETH LY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2022
Last Update Date: 08/25/2025
Certification Date: 08/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 STRYKERS RD STE 1
PHILLIPSBURG NJ
08865-9465
US

IV. Provider business mailing address

200 STRYKERS RD STE 1
PHILLIPSBURG NJ
08865-9465
US

V. Phone/Fax

Practice location:
  • Phone: 908-847-6568
  • Fax: 866-278-3009
Mailing address:
  • Phone: 908-847-6568
  • Fax: 866-278-3009

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number25MA12797600
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: