MEDICARE: DR. ROGER A COSTA DC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111NS0005X	Sports Physician Chiropractor	C03900-0	NY

General Provider Information

NPI Number	:	1013056647
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ROGER A COSTA DC

Provider Business Mailing Address
First Line	:	165 W END AVE
Second Line	:	SUITE # 1F
City	:	NEW YORK
State	:	NY
Zip	:	10023-5503
Country	:	US
Telephone Number	:	212-724-1929
Fax Number	:

Provider Business Practice Location Address
First Line	:	165 W END AVE
Second Line	:	SUITE # 1F
City	:	NEW YORK
State	:	NY
Zip	:	10023-5503
Country	:	US
Telephone Number	:	212-724-1929
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/06/2007
Last Update Date	:	07/08/2007

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