Provider Demographics
NPI:1902993090
Name:LY, ROSE VAY (MD)
Entity Type:Individual
Prefix:
First Name:ROSE VAY
Middle Name:
Last Name:LY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 95000-2436
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19195-2436
Mailing Address - Country:US
Mailing Address - Phone:212-746-0373
Mailing Address - Fax:212-746-7481
Practice Address - Street 1:10 UNION SQUARE EAST SUITE 2J
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003
Practice Address - Country:US
Practice Address - Phone:212-844-8300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-09
Last Update Date:2013-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY202408208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01749435Medicaid
NY07X611Medicare ID - Type Unspecified
NY01749435Medicaid