Provider Demographics
NPI:1760872113
Name:COSTELLO, ADRIAN
Entity Type:Individual
Prefix:
First Name:ADRIAN
Middle Name:
Last Name:COSTELLO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 MADISON AVE
Mailing Address - Street 2:5TH FLOOR
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10010-1600
Mailing Address - Country:US
Mailing Address - Phone:212-545-2438
Mailing Address - Fax:646-312-0481
Practice Address - Street 1:1167 NOSTRAND AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11225-5417
Practice Address - Country:US
Practice Address - Phone:718-778-0198
Practice Address - Fax:718-221-8169
Is Sole Proprietor?:No
Enumeration Date:2015-01-23
Last Update Date:2015-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY083805-1104100000X
NY083146-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00695941Medicaid
NY331058Medicare Oscar/Certification
NY331944Medicare Oscar/Certification
NYW6L111Medicare Oscar/Certification
NY00695941Medicaid
NY331952Medicare Oscar/Certification
NY331943Medicare Oscar/Certification
NY331947Medicare Oscar/Certification
NY331954Medicare Oscar/Certification
NY331946Medicare Oscar/Certification
NY331978Medicare Oscar/Certification
NY331009Medicare Oscar/Certification
NY331945Medicare Oscar/Certification
NYG100000410Medicare Oscar/Certification