Healthcare Provider Details

I. General information

NPI: 1598856858
Provider Name (Legal Business Name): ANDREW T. COSTARINO JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 06/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3401 CIVIC CENTER BLVD STE 9329
PHILADELPHIA PA
19104-4319
US

IV. Provider business mailing address

100 E PENN SQUARE WANAMAKER BLDG., 9TH FL, N
PHILADELPHIA PA
19104-0001
US

V. Phone/Fax

Practice location:
  • Phone: 215-590-1858
  • Fax: 267-425-9331
Mailing address:
  • Phone: 267-425-9320
  • Fax: 267-425-9331

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberC10006289
License Number StateDE
# 2
Primary TaxonomyN
Taxonomy Code207LP3000X
TaxonomyPediatric Anesthesiology Physician
License NumberC10006289
License Number StateDE
# 3
Primary TaxonomyY
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License NumberC10006289
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: