MEDICARE: NICHOLAS S COSTANZO DPT

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	225100000X	Physical Therapist	PT021349	PA

General Provider Information

NPI Number	:	1568759900
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICHOLAS S COSTANZO DPT

Provider Business Mailing Address
First Line	:	438 PELLIS RD
Second Line	:	SUITE 101
City	:	GREENSBURG
State	:	PA
Zip	:	15601-7900
Country	:	US
Telephone Number	:	724-850-7587
Fax Number	:	724-850-8329

Provider Business Practice Location Address
First Line	:	401 W. MAIN STREET
Second Line	:
City	:	NEW ALEXANDRIA
State	:	PA
Zip	:	15670-9998
Country	:	US
Telephone Number	:	724-668-7800
Fax Number	:	724-668-8908

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

Provider Enumeration Date	:	07/06/2011
Last Update Date	:	07/06/2011

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