Provider Demographics
NPI:1083609978
Name:DECOSTE, MICHELLE
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:
Last Name:DECOSTE
Suffix:
Gender:F
Credentials:
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 309
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44309-0309
Mailing Address - Country:US
Mailing Address - Phone:330-864-7106
Mailing Address - Fax:330-869-8924
Practice Address - Street 1:401 N EWING ST
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:OH
Practice Address - Zip Code:43130-3372
Practice Address - Country:US
Practice Address - Phone:740-687-8000
Practice Address - Fax:740-687-8357
Is Sole Proprietor?:No
Enumeration Date:2005-09-16
Last Update Date:2011-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35042742D207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0381064Medicaid
OHDE7225021Medicare PIN
OHD32041Medicare UPIN