MEDICARE: DR. JOSEPH PATRICK COSTELLO III MD

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	174400000X	Specialist	036079559	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	432064512	OTHER	IL	FEDERAL TAX ID
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	371390565	OTHER	IL	FEDERAL TAX ID

General Provider Information

NPI Number	:	1073607651
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOSEPH PATRICK COSTELLO III MD

Provider Business Mailing Address
First Line	:	PO BOX 217
Second Line	:
City	:	O FALLON
State	:	IL
Zip	:	62269-0217
Country	:	US
Telephone Number	:	618-233-6685
Fax Number	:	618-233-6616

Provider Business Practice Location Address
First Line	:	4212 N ILLINOIS ST
Second Line	:
City	:	SWANSEA
State	:	IL
Zip	:	62226-1835
Country	:	US
Telephone Number	:	618-233-6685
Fax Number	:	618-233-6616

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

Provider Enumeration Date	:	10/03/2006
Last Update Date	:	11/30/2011

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