Basic Information
| Provider Information | |||||||||
| NPI: | 1598714891 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DECKER | ||||||||
| FirstName: | MARY LOUISE | ||||||||
| MiddleName: | SUSAN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 250 PIERCE ST STE 203 | ||||||||
| Address2: | |||||||||
| City: | KINGSTON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 187045149 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5707142524 | ||||||||
| FaxNumber: | 5707142531 | ||||||||
| Practice Location | |||||||||
| Address1: | 501 S WASHINGTON AVE STE 1000 | ||||||||
| Address2: | |||||||||
| City: | SCRANTON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 185053814 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5709410630 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/06/2006 | ||||||||
| LastUpdateDate: | 12/11/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0200X | MD065216L | PA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
ID Information
| ID | Type | State | Issuer | Description | 101303 | 01 | PA | UNISON HEALTH PLAN | OTHER | 276915 | 01 | PA | HIGHMARK BLUE SHIELD | OTHER | 0016925830001 | 05 | PA | MEDICAID | 24497 | 01 | PA | GEISINGER HEALTH PLAN | OTHER | 806176 | 01 | PA | FIRST PRIORITY HEALTH | OTHER |