Healthcare Provider Details

I. General information

NPI: 1356634927
Provider Name (Legal Business Name): LISA MARIE COSTELLO MD, MPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2011
Last Update Date: 04/15/2022
Certification Date: 04/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 STADIUM DRIVE
MORGANTOWN WV
26506
US

IV. Provider business mailing address

1 STADIUM DRIVE
MORGANTOWN WV
26506
US

V. Phone/Fax

Practice location:
  • Phone: 304-598-4000
  • Fax:
Mailing address:
  • Phone: 304-598-4000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number25300
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: