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General NPI Number Information
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NPI Number | 1114002995
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Entity Type | Organization
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Legal Business Name | MICHAEL J COSTELLO MD PA
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Dates
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Enumeration Date | 10/27/2006
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Last Update Date | 01/16/2013
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Provider Practice Location Address
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Address Line | 2215 NEBRASKA AVE SUITE 3-D
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City | FORT PIERCE
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State | FL
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Zip | 34950-4864
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Country | US
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Telephone | 772-461-4666
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Fax | 772-464-3005
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Provider Business Mailing Address
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Address Line | 2215 NEBRASKA AVE SUITE 3-D
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City | FORT PIERCE
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State | FL
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Zip | 34950-4864
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Country | US
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Telephone | 772-461-4666
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Fax | 772-464-3005
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Authorized Official
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Title or Position | PRESIDENT
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Name | MICHAEL J COSTELLO
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Credential | M.D.
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Telephone | 772-461-4666
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | ME0026473
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License Number State | FL
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