Provider Demographics
NPI:1366593121
Name:MARY LOUISE DECKER MD
Entity type:Organization
Organization Name:MARY LOUISE DECKER MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:LOUISE
Authorized Official - Last Name:DECKER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:570-822-6036
Mailing Address - Street 1:107 LOOMIS ST
Mailing Address - Street 2:
Mailing Address - City:WILKES BARRE
Mailing Address - State:PA
Mailing Address - Zip Code:18702-4637
Mailing Address - Country:US
Mailing Address - Phone:570-822-6036
Mailing Address - Fax:
Practice Address - Street 1:107 LOOMIS ST
Practice Address - Street 2:
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18702-4637
Practice Address - Country:US
Practice Address - Phone:570-822-6036
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD065216L207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1017052180001Medicaid
PA1017052180001Medicaid
PA1017052180001Medicaid