1730104340 NPI number — MR. EDWARD T COSTELLO P.A.

Table of content: MR. EDWARD T COSTELLO P.A. (NPI 1730104340)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730104340 NPI number — MR. EDWARD T COSTELLO P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COSTELLO
Provider First Name:
EDWARD
Provider Middle Name:
T
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
P.A.
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:
1730104340
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/17/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1002 SCHNEIDER DR
Provider Second Line Business Mailing Address:
SUITE 104
Provider Business Mailing Address City Name:
MALVERN
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72104-4816
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
501-332-7981
Provider Business Mailing Address Fax Number:
501-337-9964

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1002 SCHNEIDER DR
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
MALVERN
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72104-4816
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
501-332-7981
Provider Business Practice Location Address Fax Number:
501-337-9964
Provider Enumeration Date:
07/13/2006

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: 363A00000X , with the licence number:  PA-251 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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