Provider Demographics
NPI:1114002995
Name:MICHAEL J COSTELLO MD PA
Entity Type:Organization
Organization Name:MICHAEL J COSTELLO MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:COSTELLO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:772-461-4666
Mailing Address - Street 1:2215 NEBRASKA AVE
Mailing Address - Street 2:SUITE 3-D
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34950-4864
Mailing Address - Country:US
Mailing Address - Phone:772-461-4666
Mailing Address - Fax:772-464-3005
Practice Address - Street 1:2215 NEBRASKA AVE
Practice Address - Street 2:SUITE 3-D
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34950-4864
Practice Address - Country:US
Practice Address - Phone:772-461-4666
Practice Address - Fax:772-464-3005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-27
Last Update Date:2013-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0026473208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK1505Medicare ID - Type Unspecified
FL1366470403Medicare PIN
FL1114002995Medicare PIN