Provider Demographics
NPI:1942310149
Name:PAMELA J. COSTELLO, MD, PC
Entity Type:Organization
Organization Name:PAMELA J. COSTELLO, MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:J
Authorized Official - Last Name:COSTELLO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:423-461-0073
Mailing Address - Street 1:3915 BRISTOL HWY STE 103
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37601-1400
Mailing Address - Country:US
Mailing Address - Phone:423-461-0073
Mailing Address - Fax:423-461-0076
Practice Address - Street 1:3915 BRISTOL HWY STE 103
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37601-1400
Practice Address - Country:US
Practice Address - Phone:423-461-0073
Practice Address - Fax:423-461-0076
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2019-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ05797AMedicaid
H15588Medicare UPIN