Provider Demographics
NPI:1073607651
Name:COSTELLO, JOSEPH PATRICK III (MD)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:PATRICK
Last Name:COSTELLO
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:JOSEPH
Other - Middle Name:P
Other - Last Name:COSTELLO
Other - Suffix:III
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 217
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-0217
Mailing Address - Country:US
Mailing Address - Phone:618-233-6685
Mailing Address - Fax:618-233-6616
Practice Address - Street 1:4212 N ILLINOIS ST
Practice Address - Street 2:
Practice Address - City:SWANSEA
Practice Address - State:IL
Practice Address - Zip Code:62226-1835
Practice Address - Country:US
Practice Address - Phone:618-233-6685
Practice Address - Fax:618-233-6616
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2011-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036079559174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL432064512OtherFEDERAL TAX ID
ILO36079559Medicaid
IL371390565OtherFEDERAL TAX ID