Provider Demographics
NPI:1326452921
Name:COSTELLO, REBEKAH (DO)
Entity Type:Individual
Prefix:
First Name:REBEKAH
Middle Name:
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 MARKET LN
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53144-3430
Mailing Address - Country:US
Mailing Address - Phone:262-551-4600
Mailing Address - Fax:262-653-5850
Practice Address - Street 1:3400 MARKET LN
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53144-3430
Practice Address - Country:US
Practice Address - Phone:262-551-4600
Practice Address - Fax:262-551-4630
Is Sole Proprietor?:No
Enumeration Date:2014-06-12
Last Update Date:2019-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.144957207Q00000X, 207Q00000X
WI71089-21207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036.144957OtherILLINOIS MEDICAL LICENSE
WI1326452921Medicaid