Provider Demographics
NPI:1154372373
Name:WYOMING VALLEY INFECTIOUS DISEASE ASSOC, PC
Entity type:Organization
Organization Name:WYOMING VALLEY INFECTIOUS DISEASE ASSOC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:R
Authorized Official - Last Name:DECKER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:570-822-6036
Mailing Address - Street 1:545 N RIVER ST
Mailing Address - Street 2:SUITE 205
Mailing Address - City:WILKES BARRE
Mailing Address - State:PA
Mailing Address - Zip Code:18702-2600
Mailing Address - Country:US
Mailing Address - Phone:570-822-6036
Mailing Address - Fax:570-829-1520
Practice Address - Street 1:545 N RIVER ST
Practice Address - Street 2:SUITE 205
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18702-2600
Practice Address - Country:US
Practice Address - Phone:570-822-6036
Practice Address - Fax:570-829-1520
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-12
Last Update Date:2010-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA756235OtherHIGHMARK BLUE SHIELD
PA809669OtherFIRST PRIORITY
PA010284600OtherBLACK LUNG
PA5507OtherGEISINGER HEALTH PLAN
PA0017767900002Medicaid
PA756235OtherFIRST PRIORITY LIFE
PA0017767900002Medicaid