Provider Demographics
NPI:1710986781
Name:COSTELLO, THOMAS H (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:H
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 1:100 TRADECENTER
Mailing Address - Street 2:SUITE 750
Mailing Address - City:WOBURN
Mailing Address - State:MA
Mailing Address - Zip Code:01801-1851
Mailing Address - Country:US
Mailing Address - Phone:781-937-3001
Mailing Address - Fax:781-937-3070
Practice Address - Street 1:100 TRADECENTER
Practice Address - Street 2:SUITE 750
Practice Address - City:WOBURN
Practice Address - State:MA
Practice Address - Zip Code:01801-1851
Practice Address - Country:US
Practice Address - Phone:781-937-3001
Practice Address - Fax:781-937-3070
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2014-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA466552207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAM12237OtherMEDICARE GROUP
MAI32185Medicare UPIN
MAA38503Medicare PIN