Healthcare Provider Details

I. General information

NPI: 1396897526
Provider Name (Legal Business Name): DECATUR OBGYN ASSOCIATES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2007
Last Update Date: 08/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEMORIAL DR SUITE 300
DECATUR IL
62526-6303
US

IV. Provider business mailing address

1 MEMORIAL DR SUITE 300
DECATUR IL
62526-6303
US

V. Phone/Fax

Practice location:
  • Phone: 217-875-5545
  • Fax:
Mailing address:
  • Phone: 217-875-5545
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number036072402
License Number StateIL

VIII. Authorized Official

Name: DR. ROY TSUDA
Title or Position: VICE PRESIDENT
Credential: M.D.
Phone: 217-875-5545