Healthcare Provider Details

I. General information

NPI: 1396107751
Provider Name (Legal Business Name): RYAN COSTELLO DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2016
Last Update Date: 10/06/2026
Certification Date: 10/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1520 UNION AVE
MEMPHIS TN
38174-0275
US

IV. Provider business mailing address

350 N HUMPHREYS BLVD
MEMPHIS TN
38120-2177
US

V. Phone/Fax

Practice location:
  • Phone: 901-276-2410
  • Fax: 901-261-6010
Mailing address:
  • Phone: 901-227-4003
  • Fax: 901-227-8591

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberE-11969
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number32754
License Number StateMS
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4623
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: