Provider Demographics
NPI:1790154540
Name:ROBERT COSTELLO MD LLC
Entity Type:Organization
Organization Name:ROBERT COSTELLO MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED REPRESENTATIVE
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:E
Authorized Official - Last Name:COSTELLO
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:201-390-8705
Mailing Address - Street 1:220 HAMBURG TPKE
Mailing Address - Street 2:SUITE 8
Mailing Address - City:WAYNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07470-2110
Mailing Address - Country:US
Mailing Address - Phone:973-942-5230
Mailing Address - Fax:973-942-6652
Practice Address - Street 1:220 HAMBURG TPKE
Practice Address - Street 2:SUITE 8
Practice Address - City:WAYNE
Practice Address - State:NJ
Practice Address - Zip Code:07470-2110
Practice Address - Country:US
Practice Address - Phone:973-942-5230
Practice Address - Fax:973-942-6652
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-23
Last Update Date:2015-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty