Basic Information
| Provider Information | |||||||||
| NPI: | 1134650922 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | LY | ||||||||
| FirstName: | EDDIE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 17360 BROOKHURST STREEET | ||||||||
| Address2: | ATTN: NETWORK MANAGEMENT | ||||||||
| City: | FOUNTAIN VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7143772900 | ||||||||
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| Practice Location | |||||||||
| Address1: | 17360 BROOKHURST ST | ||||||||
| Address2: | |||||||||
| City: | FOUNTAIN VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 927083720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7146651797 | ||||||||
| FaxNumber: | 7146654680 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2017 | ||||||||
| LastUpdateDate: | 06/01/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | A159769 | CA | N | Allopathic & Osteopathic Physicians | Hospitalist | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207R00000X | A159769 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.