Provider Demographics
NPI:1689972606
Name:MICHAEL J DECOSMO DO PA
Entity Type:Organization
Organization Name:MICHAEL J DECOSMO DO PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:DECOSMO
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:856-662-7883
Mailing Address - Street 1:2201 CHAPEL AVE WEST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:CHERRY HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08002
Mailing Address - Country:US
Mailing Address - Phone:856-662-7883
Mailing Address - Fax:856-662-5838
Practice Address - Street 1:2201 CHAPEL AVE WEST
Practice Address - Street 2:SUITE 102
Practice Address - City:CHERRY HILL
Practice Address - State:NJ
Practice Address - Zip Code:08002
Practice Address - Country:US
Practice Address - Phone:856-662-7883
Practice Address - Fax:856-662-5838
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-01
Last Update Date:2011-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB02598600207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty