MEDICARE: DR. GEORGE P. COSTANZO M.D.

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	208600000X	Surgery Physician	55933	GA

General Provider Information

NPI Number	:	1427030634
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GEORGE P. COSTANZO M.D.

Provider Business Mailing Address
First Line	:	3278 MICTCHELL BLVD
Second Line	:
City	:	MOODY AFB
State	:	GA
Zip	:	31699-1500
Country	:	US
Telephone Number	:	229-257-3891
Fax Number	:

Provider Business Practice Location Address
First Line	:	347TH MEDICAL GROUP
Second Line	:	3278 MITCHELL BLVD
City	:	MOODY A F B
State	:	GA
Zip	:	31699-0001
Country	:	US
Telephone Number	:	229-257-3755
Fax Number	:	229-257-4672

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

Provider Enumeration Date	:	11/15/2005
Last Update Date	:	07/08/2007

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Directions to “ DR. GEORGE P. COSTANZO M.D.” Practice Location

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