Healthcare Provider Details

I. General information

NPI: 1740250125
Provider Name (Legal Business Name): MICHAEL W COSTELLO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2006
Last Update Date: 01/25/2024
Certification Date: 01/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22911 JEFFERSON BLVD
SMITHSBURG MD
21783-1617
US

IV. Provider business mailing address

22911 JEFFERSON BLVD
SMITHSBURG MD
21783-1617
US

V. Phone/Fax

Practice location:
  • Phone: 301-824-3343
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberD0041378
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: