Provider Demographics
NPI:1396897526
Name:DECATUR OBGYN ASSOCIATES, LLC
Entity type:Organization
Organization Name:DECATUR OBGYN ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROY
Authorized Official - Middle Name:
Authorized Official - Last Name:TSUDA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:217-875-5545
Mailing Address - Street 1:1 MEMORIAL DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62526-6303
Mailing Address - Country:US
Mailing Address - Phone:217-875-5545
Mailing Address - Fax:
Practice Address - Street 1:1 MEMORIAL DR
Practice Address - Street 2:SUITE 300
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526-6303
Practice Address - Country:US
Practice Address - Phone:217-875-5545
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-17
Last Update Date:2008-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036072402207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036086221Medicaid
IL036087950Medicaid
IL020005538OtherMEDICARE RAILROAD
IL036098445Medicaid
IL036104247Medicaid
IL036072402Medicaid
IL160055053OtherMEDICARE RAILROAD
IL1396897526OtherMEDICARE RAILROAD
IL160020964OtherMEDICARE RAILROAD
IL160057787OtherMEDICARE RAILROAD
ILCM4913OtherMEDICARE RAILROAD
IL160055053OtherMEDICARE RAILROAD
IL160020964OtherMEDICARE RAILROAD
ILF54210Medicare UPIN
IL036087950Medicaid
ILL89205Medicare PIN
ILL35247Medicare PIN
ILC47968Medicare UPIN
ILH37400Medicare UPIN
ILH15258Medicare UPIN
IL036086221Medicaid
IL036072402Medicaid