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General NPI Number Information
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NPI Number | 1891004685
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Entity Type | Organization
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Legal Business Name | EASTERN REGIONAL PAIN MGT
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Dates
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Enumeration Date | 09/28/2010
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Last Update Date | 09/28/2010
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Provider Practice Location Address
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Address Line | 151 FRIES MILL RD.
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City | TURNERSVILLE
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State | NJ
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Zip | 08012
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Country | US
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Telephone | 215-945-8882
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Fax | 215-945-9129
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Provider Business Mailing Address
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Address Line | 333. S. OXFORD VALLEY RD. STE 606
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City | FAIRLESS HILLS
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State | PA
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Zip | 19030
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Country | US
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Telephone | 215-945-8882
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Fax | 215-945-9129
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Authorized Official
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Title or Position | PAIN DOCTOR ANESTHESIOLOGY/PAIN MAN
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Name | DR. THOMAS P COSTELLO
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Credential | DO
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Telephone | 215-945-8882
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207LP2900X
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Taxonomy Name | Pain Medicine (Anesthesiology) Physician
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License Number | 05005840L
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License Number State | PA
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Taxonomy #2
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Taxonomy Code | 207LP2900X
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Taxonomy Name | Pain Medicine (Anesthesiology) Physician
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License Number | MB50806
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License Number State | NJ
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