Provider Demographics
NPI:1598714891
Name:DECKER, MARY LOUISE SUSAN (MD)
Entity Type:Individual
Prefix:
First Name:MARY LOUISE
Middle Name:SUSAN
Last Name:DECKER
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 1:250 PIERCE ST STE 203
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:PA
Mailing Address - Zip Code:18704-5149
Mailing Address - Country:US
Mailing Address - Phone:570-714-2524
Mailing Address - Fax:570-714-2531
Practice Address - Street 1:501 S WASHINGTON AVE STE 1000
Practice Address - Street 2:
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18505-3814
Practice Address - Country:US
Practice Address - Phone:570-941-0630
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-06
Last Update Date:2020-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD065216L207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA101303OtherUNISON HEALTH PLAN
PA276915OtherHIGHMARK BLUE SHIELD
PA0016925830001Medicaid
PA24497OtherGEISINGER HEALTH PLAN
PA806176OtherFIRST PRIORITY HEALTH
PAG69084Medicare UPIN
PA24497OtherGEISINGER HEALTH PLAN