Healthcare Provider Details

I. General information

NPI: 1043435340
Provider Name (Legal Business Name): PETRONILO R COSTA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/13/2007
Last Update Date: 10/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 LAKE COOK RD STE 118
DEERFIELD IL
60015-4914
US

IV. Provider business mailing address

420 LAKE COOK RD STE 118
DEERFIELD IL
60015-4914
US

V. Phone/Fax

Practice location:
  • Phone: 847-205-0237
  • Fax: 866-735-3898
Mailing address:
  • Phone: 847-205-0237
  • Fax: 866-735-3898

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036-046-108
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number036-046-108
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code2080P0006X
TaxonomyDevelopmental - Behavioral Pediatrics Physician
License Number036-046-108
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code2080P0008X
TaxonomyPediatric Neurodevelopmental Disabilities Physician
License Number036-046-108
License Number StateIL
# 5
Primary TaxonomyY
Taxonomy Code2083P0011X
TaxonomyUndersea and Hyperbaric Medicine (Preventive Medicine) Physician
License Number036-046-108
License Number StateIL
# 6
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number036-046-108
License Number StateIL
# 7
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number036-046-108
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: