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General NPI Number Information
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NPI Number | 1053302992
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Entity Type | Individual
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Provider Name | JOHN COSTELLO MD
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Gender | Male
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Dates
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Enumeration Date | 10/31/2005
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Last Update Date | 02/18/2022
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Provider Practice Location Address
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Address Line | 171 ASHLEY AVE
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City | CHARLESTON
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State | SC
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Zip | 29425
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Country | US
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Telephone | 843-792-1414
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 751461
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City | CHARLOTTE
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State | NC
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Zip | 28275-1461
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Country | US
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Telephone | 843-792-6200
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Fax | 603-893-8886
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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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 | 217260
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License Number State | MA
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Taxonomy #2
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Taxonomy Code | 2080P0202X
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Taxonomy Name | Pediatric Cardiology Physician
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License Number | 52686
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License Number State | SC
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Taxonomy #3
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Taxonomy Code | 2080P0203X
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Taxonomy Name | Pediatric Critical Care Medicine Physician
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License Number | 52686
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License Number State | SC
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