MEDICARE: MARY JO COSTELLO RD

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	133V00000X	Registered Dietitian	DN002628	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	630384	OTHER	PA	AMER DIETETIC ASSOC

General Provider Information

NPI Number	:	1932258142
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY JO COSTELLO RD

Provider Business Mailing Address
First Line	:	269 NEWBURN DR
Second Line	:
City	:	PITTSBURGH
State	:	PA
Zip	:	15216-1213
Country	:	US
Telephone Number	:	412-310-0720
Fax Number	:	717-616-9251

Provider Business Practice Location Address
First Line	:	269 NEWBURN DR
Second Line	:
City	:	PITTSBURGH
State	:	PA
Zip	:	15216-1213
Country	:	US
Telephone Number	:	412-310-0720
Fax Number	:	717-616-9251

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

Provider Enumeration Date	:	01/09/2007
Last Update Date	:	07/08/2007

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