Provider Demographics
NPI:1710931001
Name:COSTELLO, ANDREW (MD)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:COSTELLO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2740 W FOSTER AVE STE 310
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-3547
Mailing Address - Country:US
Mailing Address - Phone:773-878-8200
Mailing Address - Fax:773-293-8804
Practice Address - Street 1:5145 N CALIFORNIA AVENUE
Practice Address - Street 2:SWEDISH COVENANT HOSPITAL
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625
Practice Address - Country:US
Practice Address - Phone:773-878-8200
Practice Address - Fax:630-734-1560
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036097665207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036097665Medicaid
ILK27168Medicare ID - Type Unspecified