Healthcare Provider Details

I. General information

NPI: 1245496819
Provider Name (Legal Business Name): HEATHER HELENE COSTELLO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2008
Last Update Date: 10/09/2024
Certification Date: 10/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2650 RIDGE AVE
EVANSTON IL
60201-1718
US

IV. Provider business mailing address

2050 CLAIRE CT
GLENVIEW IL
60025-7635
US

V. Phone/Fax

Practice location:
  • Phone: 847-570-2114
  • Fax:
Mailing address:
  • Phone: 847-570-2114
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number036122460
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207PH0002X
TaxonomyHospice and Palliative Medicine (Emergency Medicine) Physician
License Number036122460
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: