Provider Demographics
NPI:1659570331
Name:COSTELLO, THOMAS P (DO)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:P
Last Name:COSTELLO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:4979 OLD STREET RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:TREVOSE
Mailing Address - State:PA
Mailing Address - Zip Code:19053-6222
Mailing Address - Country:US
Mailing Address - Phone:215-953-8882
Mailing Address - Fax:215-953-8822
Practice Address - Street 1:4979 OLD STREET RD
Practice Address - Street 2:SUITE A
Practice Address - City:TREVOSE
Practice Address - State:PA
Practice Address - Zip Code:19053-6222
Practice Address - Country:US
Practice Address - Phone:215-953-8882
Practice Address - Fax:215-953-8822
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-13
Last Update Date:2011-10-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAOS005840L207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA564403Medicare PIN
PAE23610Medicare UPIN