Provider Demographics
NPI:1578628673
Name:DECOTIIS MEDICAL LLC
Entity type:Organization
Organization Name:DECOTIIS MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SUE
Authorized Official - Middle Name:
Authorized Official - Last Name:DECOTIIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:212-685-3640
Mailing Address - Street 1:104 E 40TH ST RM 606
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-1801
Mailing Address - Country:US
Mailing Address - Phone:212-685-3640
Mailing Address - Fax:
Practice Address - Street 1:104 E 40TH ST RM 606
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-1801
Practice Address - Country:US
Practice Address - Phone:212-685-3640
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYB14319Medicare UPIN