MEDICARE: SANDRA COSTLEY MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	185092	NY

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	SC089K6010	OTHER	NY	MEDICARE UNSPECIFIED

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1174507479
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SANDRA COSTLEY MD

Provider Business Mailing Address
First Line	:	17 SQUADRON BLVD
Second Line	:	SUITE 400
City	:	NEW CITY
State	:	NY
Zip	:	10956-5214
Country	:	US
Telephone Number	:	845-634-6500
Fax Number	:	845-634-9424

Provider Business Practice Location Address
First Line	:	345 N MAIN ST
Second Line	:
City	:	NEW CITY
State	:	NY
Zip	:	10956-4305
Country	:	US
Telephone Number	:	845-639-3123
Fax Number	:	845-639-4194

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/01/2005
Last Update Date	:	04/23/2008

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Directions to “ SANDRA COSTLEY MD” Practice Location

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