Healthcare Provider Details

I. General information

NPI: 1619172970
Provider Name (Legal Business Name): AESTHETIC PAVILION AMBULATORY SURGERY CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2777 HYLAN BLVD
STATEN ISLAND NY
10306-4660
US

IV. Provider business mailing address

2777 HYLAN BLVD
STATEN ISLAND NY
10306-4660
US

V. Phone/Fax

Practice location:
  • Phone: 718-987-9165
  • Fax: 718-987-0305
Mailing address:
  • Phone: 718-987-9165
  • Fax: 718-987-0305

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR1100X
TaxonomyResearch Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JOHN WILLIAM DECORATO
Title or Position: PRESIDENT
Credential: MD
Phone: 718-987-9165