Provider Demographics
NPI:1922065986
Name:EASTERN REGIONAL PAIN MANAGEMENT, P.C.
Entity Type:Organization
Organization Name:EASTERN REGIONAL PAIN MANAGEMENT, P.C.
Other - Org Name:THOMAS P COSTELLO DO
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:P
Authorized Official - Last Name:COSTELLO
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:215-953-8882
Mailing Address - Street 1:4979 OLD STREET RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:TREVOSE
Mailing Address - State:PA
Mailing Address - Zip Code:19053-6222
Mailing Address - Country:US
Mailing Address - Phone:215-953-8882
Mailing Address - Fax:215-953-8822
Practice Address - Street 1:4979 OLD STREET RD
Practice Address - Street 2:SUITE 1A
Practice Address - City:TREVOSE
Practice Address - State:PA
Practice Address - Zip Code:19053-6222
Practice Address - Country:US
Practice Address - Phone:215-953-8882
Practice Address - Fax:215-953-8822
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-26
Last Update Date:2012-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMB50806207LP2900X
PAOS005840L207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA2006338000OtherIBC
PA124642Medicare PIN
E23610Medicare UPIN