MEDICARE: DR. SCOTT J COSTLEY DO

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	207Q00000X	Family Medicine Physician	220562-1	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	10053447	OTHER	NY	CDPHP
3	087245	OTHER	NY	MVP

General Provider Information

NPI Number	:	1881697423
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SCOTT J COSTLEY DO

Provider Business Mailing Address
First Line	:	117 MARYS AVE
Second Line	:	STE 101
City	:	KINGSTON
State	:	NY
Zip	:	12401
Country	:	US
Telephone Number	:	845-339-1515
Fax Number	:	845-331-1996

Provider Business Practice Location Address
First Line	:	1089 RT 32
Second Line	:
City	:	ROSENDALE
State	:	NY
Zip	:	12472
Country	:	US
Telephone Number	:	845-658-9476
Fax Number	:	845-658-9745

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

Provider Enumeration Date	:	05/27/2005
Last Update Date	:	07/08/2009

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