Basic Information
| Provider Information | |||||||||
| NPI: | 1396897526 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DECATUR OBGYN ASSOCIATES, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 MEMORIAL DR | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | DECATUR | ||||||||
| State: | IL | ||||||||
| PostalCode: | 625266303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2178755545 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1 MEMORIAL DR | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | DECATUR | ||||||||
| State: | IL | ||||||||
| PostalCode: | 625266303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2178755545 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2007 | ||||||||
| LastUpdateDate: | 08/07/2008 | ||||||||
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| AuthorizedOfficialLastName: | TSUDA | ||||||||
| AuthorizedOfficialFirstName: | ROY | ||||||||
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| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2178755545 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 036072402 | IL | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 036086221 | 05 | IL | MEDICAID | 036087950 | 05 | IL | MEDICAID | 020005538 | 01 | IL | MEDICARE RAILROAD | OTHER | 036098445 | 05 | IL | MEDICAID | 036104247 | 05 | IL | MEDICAID | 036072402 | 05 | IL | MEDICAID | 160055053 | 01 | IL | MEDICARE RAILROAD | OTHER | 1396897526 | 01 | IL | MEDICARE RAILROAD | OTHER | 160020964 | 01 | IL | MEDICARE RAILROAD | OTHER | 160057787 | 01 | IL | MEDICARE RAILROAD | OTHER | CM4913 | 01 | IL | MEDICARE RAILROAD | OTHER |