Provider Demographics
NPI:1669522199
Name:J L COSTIN, MD, PC
Entity type:Organization
Organization Name:J L COSTIN, MD, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUE
Authorized Official - Middle Name:E
Authorized Official - Last Name:COSTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-785-8405
Mailing Address - Street 1:PO BOX 4057
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63902-4057
Mailing Address - Country:US
Mailing Address - Phone:573-785-8405
Mailing Address - Fax:573-778-0425
Practice Address - Street 1:3069 N WESTWOOD BLVD
Practice Address - Street 2:STE A
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901
Practice Address - Country:US
Practice Address - Phone:573-785-8405
Practice Address - Fax:573-778-0425
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-10
Last Update Date:2007-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR98839OtherARK FIRST SOURCE
MO98839OtherARKANSAS FIRST SOURCE
MO119564OtherBLUE CROSS BLUE SHIELD
MO654990OtherFIRST HEALTH
MO114817OtherHEALTHLINK
MO74954OtherBLUE CROSS BLUE SHIELD AL
MOP00199451OtherRAILROAD MEDICARE
MOA11628Medicare UPIN