Provider Demographics
NPI:1811367402
Name:THOMAS E. COSTELLO, MD, PT, PLLC
Entity Type:Organization
Organization Name:THOMAS E. COSTELLO, MD, PT, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:E
Authorized Official - Last Name:COSTELLO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:516-658-2807
Mailing Address - Street 1:PO BOX 464
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11746-0374
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14 VILLANOVA LN
Practice Address - Street 2:
Practice Address - City:DIX HILLS
Practice Address - State:NY
Practice Address - Zip Code:11746-4841
Practice Address - Country:US
Practice Address - Phone:516-658-2807
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-25
Last Update Date:2023-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011915261QP2000X
NY267336261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy