Provider Demographics
NPI:1649593211
Name:COSTELLO, MICHAEL JOHN (PT)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JOHN
Last Name:COSTELLO
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 1:310 TAUGHANNOCK BLVD
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-3251
Mailing Address - Country:US
Mailing Address - Phone:607-252-3500
Mailing Address - Fax:607-252-3505
Practice Address - Street 1:310 TAUGHANNOCK BLVD
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-3251
Practice Address - Country:US
Practice Address - Phone:607-252-3500
Practice Address - Fax:607-252-3505
Is Sole Proprietor?:No
Enumeration Date:2010-03-10
Last Update Date:2010-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017819-12251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY22-2325405OtherEMPLOYER FEDERAL TAX IDENTIFICATION CAYUGA MEDICAL CENTER AT ITHACA
NY00332729Medicaid
NY22-2325405OtherEMPLOYER FEDERAL TAX IDENTIFICATION CAYUGA MEDICAL CENTER AT ITHACA