Provider Demographics
NPI:1821388984
Name:COSTELLO, TIRZA M (MD)
Entity Type:Individual
Prefix:
First Name:TIRZA
Middle Name:M
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2753 ERIE AVE
Mailing Address - Street 2:SECOND FLOOR
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45208-2204
Mailing Address - Country:US
Mailing Address - Phone:513-481-9700
Mailing Address - Fax:513-389-7091
Practice Address - Street 1:6350 GLENWAY AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45211-6378
Practice Address - Country:US
Practice Address - Phone:513-481-9700
Practice Address - Fax:513-389-7091
Is Sole Proprietor?:No
Enumeration Date:2011-04-11
Last Update Date:2015-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35123254208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics