MEDICARE: CHRISTINE ELIZABETH COSTA M.D.

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	208000000X	Pediatrics Physician	300652	NY
2	208000000X	Pediatrics Physician	25MA11443100	NJ

General Provider Information

NPI Number	:	1417311911
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHRISTINE ELIZABETH COSTA M.D.

Provider Business Mailing Address
First Line	:	401 ROUTE 73 N STE 320
Second Line	:
City	:	MARLTON
State	:	NJ
Zip	:	08053-3426
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	95 N WASHINGTON AVE
Second Line	:
City	:	BERGENFIELD
State	:	NJ
Zip	:	07621-1751
Country	:	US
Telephone Number	:	201-384-0300
Fax Number	:

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

Provider Enumeration Date	:	04/11/2016
Last Update Date	:	06/03/2022

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