1669522199 NPI number — J L COSTIN, MD, PC

Table of content: (NPI 1669522199)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669522199 NPI number — J L COSTIN, MD, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
J L COSTIN, MD, PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1669522199
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/28/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 4057
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
POPLAR BLUFF
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63902-4057
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
573-785-8405
Provider Business Mailing Address Fax Number:
573-778-0425

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3069 N WESTWOOD BLVD
Provider Second Line Business Practice Location Address:
STE A
Provider Business Practice Location Address City Name:
POPLAR BLUFF
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63901
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-785-8405
Provider Business Practice Location Address Fax Number:
573-778-0425
Provider Enumeration Date:
01/10/2007

Additional Information

Authorized Official

Authorized Official Last Name:
COSTIN
Authorized Official First Name:
SUE
Authorized Official Middle Name:
E
Authorized Official Title or Position:
DIRECTOR OF OPERATIONS
Authorized Official Telephone Number:
573-785-8405

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 98839 . This is a "ARK FIRST SOURCE" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 98839 . This is a "ARKANSAS FIRST SOURCE" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 119564 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 654990 . This is a "FIRST HEALTH" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 114817 . This is a "HEALTHLINK" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 74954 . This is a "BLUE CROSS BLUE SHIELD AL" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: P00199451 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




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