Healthcare Provider Details

I. General information

NPI: 1356778542
Provider Name (Legal Business Name): DECOSY HERCULES D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2013
Last Update Date: 10/12/2023
Certification Date: 10/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 OSTRUM ST STE 2
BETHLEHEM PA
18015-1000
US

IV. Provider business mailing address

801 OSTRUM ST STE 2
BETHLEHEM PA
18015-1000
US

V. Phone/Fax

Practice location:
  • Phone: 484-526-1735
  • Fax: 484-526-2429
Mailing address:
  • Phone: 484-526-1735
  • Fax: 484-526-2429

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberOS018633
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: