Provider Demographics
NPI:1780758854
Name:COSTELLO, ROBERT M (DC, CCEP)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:M
Last Name:COSTELLO
Suffix:
Gender:M
Credentials:DC, CCEP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1005 PERRY HWY
Mailing Address - Street 2:SUITE 1
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15237-2108
Mailing Address - Country:US
Mailing Address - Phone:412-366-6404
Mailing Address - Fax:412-366-3716
Practice Address - Street 1:1005 PERRY HWY
Practice Address - Street 2:SUITE 1
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15237-2108
Practice Address - Country:US
Practice Address - Phone:412-366-6404
Practice Address - Fax:412-366-3716
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC002312L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA184864OtherHIGHMARK BCBS
PA251413863OtherTAX ID NUMBER
PA184864Medicare ID - Type Unspecified