Provider Demographics
NPI:1417913450
Name:COSTABILE, ERMANNO RENATO (PT)
Entity Type:Individual
Prefix:
First Name:ERMANNO
Middle Name:RENATO
Last Name:COSTABILE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7110 HARLAN LN
Mailing Address - Street 2:
Mailing Address - City:SYKESVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21784-7559
Mailing Address - Country:US
Mailing Address - Phone:410-549-9225
Mailing Address - Fax:
Practice Address - Street 1:700 GEIPE RD
Practice Address - Street 2:STE 240
Practice Address - City:CATONSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21228-4147
Practice Address - Country:US
Practice Address - Phone:410-747-8571
Practice Address - Fax:410-747-9050
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-26
Last Update Date:2007-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD16246225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD189N192GMedicare ID - Type UnspecifiedPART B