1053302992 NPI number — JOHN COSTELLO MD

Table of content: JOHN COSTELLO MD (NPI 1053302992)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053302992 NPI number — JOHN COSTELLO MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COSTELLO
Provider First Name:
JOHN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053302992
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/18/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 751461
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28275-1461
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-792-6200
Provider Business Mailing Address Fax Number:
603-893-8886

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
171 ASHLEY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHARLESTON
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29425
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-792-1414
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/31/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  217260 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2080P0202X , with the licence number: 52686 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2080P0203X , with the licence number: 52686 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2014416 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 97288001 . This is a "NETWORK HEALTH" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: TUFTS HEALTH PLAN . This is a "217260" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: JC51504 , issued by the state of ( RI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 25-01706 . This is a "UNITED HEALTHCARE MA" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: J26530 . This is a "HMO BLUE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 3253447 . This is a "AETNA MA" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 26528 . This is a "BMC HEALTHNET" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 32292 . This is a "NEIGHBORHOOD HEALTH PLAN" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: AA9211 . This is a "HARVARD PILGRIM" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: J26530 . This is a "BCBS MA" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: J26530 . This is a "BLUE CARE ELECT" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com