MEDICARE: COURTNEY JEAN COSTILOW R.EEGT.

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	246ZE0600X	Electroneurodiagnostic Specialist/Technologist
2	246ZE0600X	Electroneurodiagnostic Specialist/Technologist	4897

General Provider Information

NPI Number	:	1588256028
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	COURTNEY JEAN COSTILOW R.EEGT.

Provider Business Mailing Address
First Line	:	3410 W TACON ST
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33629-7927
Country	:	US
Telephone Number	:	813-802-8502
Fax Number	:

Provider Business Practice Location Address
First Line	:	3410 W TACON ST
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33629-7927
Country	:	US
Telephone Number	:	813-802-8502
Fax Number	:

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

Provider Enumeration Date	:	02/05/2021
Last Update Date	:	02/05/2021

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