Provider Demographics
NPI:1104205764
Name:EDWARD P. COSTLOW, MD PA
Entity Type:Organization
Organization Name:EDWARD P. COSTLOW, MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:P
Authorized Official - Last Name:COSTLOW
Authorized Official - Suffix:
Authorized Official - Credentials:MD PA
Authorized Official - Phone:410-561-1585
Mailing Address - Street 1:10 GERARD AVENUE
Mailing Address - Street 2:SUITE 214
Mailing Address - City:TIMONIUM
Mailing Address - State:MD
Mailing Address - Zip Code:21093-3206
Mailing Address - Country:US
Mailing Address - Phone:410-561-1585
Mailing Address - Fax:410-252-0814
Practice Address - Street 1:10 GERARD AVENUE
Practice Address - Street 2:SUITE 214
Practice Address - City:TIMONIUM
Practice Address - State:MD
Practice Address - Zip Code:21093-3206
Practice Address - Country:US
Practice Address - Phone:410-561-1585
Practice Address - Fax:410-252-0814
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-28
Last Update Date:2015-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0019503207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDD74585Medicare UPIN