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General NPI Number Information
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NPI Number | 1003052028
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Entity Type | Organization
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Legal Business Name | COSKIDS PEDIATRICS LTD
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Dates
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Enumeration Date | 12/22/2008
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Last Update Date | 12/22/2008
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Provider Practice Location Address
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Address Line | 4212 N ILLINOIS ST
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City | SWANSEA
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State | IL
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Zip | 62226-1835
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Country | US
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Telephone | 618-233-6685
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 217
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City | O FALLON
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State | IL
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Zip | 62269-0217
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Country | US
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Telephone | 618-233-6685
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. JOSEPH PATICK COSTELLO III
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Credential | M.D.
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Telephone | 618-233-6685
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | 036079559
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License Number State | IL
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