Provider Demographics
NPI:1083609192
Name:COSTELLO, MICHAEL (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:COSTELLO
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4967 CROOKS RD
Mailing Address - Street 2:SUITE 120
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48098-5801
Mailing Address - Country:US
Mailing Address - Phone:248-952-1601
Mailing Address - Fax:248-952-5781
Practice Address - Street 1:4967 CROOKS RD
Practice Address - Street 2:SUITE 120
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48098-5801
Practice Address - Country:US
Practice Address - Phone:248-952-1601
Practice Address - Fax:248-952-5781
Is Sole Proprietor?:No
Enumeration Date:2005-09-14
Last Update Date:2012-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003192363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
P17422Medicare UPIN
N84320013Medicare ID - Type Unspecified