Provider Demographics
NPI:1457365876
Name:COSTELLO, PAMELA J (MD)
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:J
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 1:3915 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 301
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37601-1403
Practice Address - Country:US
Practice Address - Phone:423-461-0073
Practice Address - Fax:234-610-0764
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2019-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD00000565972084N0400X
NMMD-2009-0520207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ050671Medicaid
PA0018008960003Medicaid