=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669522199
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | J L COSTIN, MD, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/10/2007
-----------------------------------------------------
Last Update Date | 11/28/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3069 N WESTWOOD BLVD STE A
-----------------------------------------------------
City | POPLAR BLUFF
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63901
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-785-8405
-----------------------------------------------------
Fax | 573-778-0425
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 4057
-----------------------------------------------------
City | POPLAR BLUFF
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63902-4057
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-785-8405
-----------------------------------------------------
Fax | 573-778-0425
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF OPERATIONS
-----------------------------------------------------
Name | MRS. SUE E COSTIN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 573-785-8405
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------