Provider Demographics
NPI:1508820085
Name:KOSTEK, EDWARD K (PT)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:K
Last Name:KOSTEK
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 1:147 MILK ST
Mailing Address - Street 2:PROVIDER ENROLLMENT 9TH FLOOR
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02109-4806
Mailing Address - Country:US
Mailing Address - Phone:617-559-8051
Mailing Address - Fax:
Practice Address - Street 1:228 BILLERICA RD
Practice Address - Street 2:
Practice Address - City:CHELMSFORD
Practice Address - State:MA
Practice Address - Zip Code:01824-3604
Practice Address - Country:US
Practice Address - Phone:978-250-6040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2009-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA17292225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAHV0001OtherHARVARD PILGRIM
MAB501027OtherCIGNA
MA908025OtherTUFTS HEALTH PLAN
MAY68457OtherBLUE CROSS
MA0035802OtherNEIGHBORHOOD HEALTH PLAN
MAY68457OtherBLUE CROSS