Provider Demographics
NPI:1598937955
Name:LAWRENCE WILLIAM COSTA, JR.
Entity Type:Organization
Organization Name:LAWRENCE WILLIAM COSTA, JR.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:VONNA
Authorized Official - Middle Name:K
Authorized Official - Last Name:LAYNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:931-924-4200
Mailing Address - Street 1:PO BOX 9
Mailing Address - Street 2:
Mailing Address - City:MONTEAGLE
Mailing Address - State:TN
Mailing Address - Zip Code:37356-0009
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1410 UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:SEWANEE
Practice Address - State:TN
Practice Address - Zip Code:37375-2304
Practice Address - Country:US
Practice Address - Phone:931-924-4200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-26
Last Update Date:2008-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3722428Medicare PIN