Basic Information
| Provider Information | |||||||||
| NPI: | 1124000864 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DECUNZO | ||||||||
| FirstName: | LOUIS | ||||||||
| MiddleName: | PETER | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 PARK STREET | ||||||||
| Address2: | |||||||||
| City: | GLENS FALLS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 128014413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5189265924 | ||||||||
| FaxNumber: | 5189266983 | ||||||||
| Practice Location | |||||||||
| Address1: | 14 HUDSON AVENUE | ||||||||
| Address2: | SURGICAL SPECIALISTS OF GLENS FALLS HOSPITAL | ||||||||
| City: | GLENS FALLS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 128014443 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5189265600 | ||||||||
| FaxNumber: | 5189265605 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/17/2005 | ||||||||
| LastUpdateDate: | 02/10/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208G00000X | 201484 | NY | Y | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
ID Information
| ID | Type | State | Issuer | Description | 01617601 | 05 | NY | MEDICAID | P00402831 | 01 | NY | RR MEDICARE | OTHER |