Basic Information
| Provider Information | |||||||||
| NPI: | 1053302992 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | COSTELLO | ||||||||
| FirstName: | JOHN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 751461 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282751461 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437926200 | ||||||||
| FaxNumber: | 6038938886 | ||||||||
| Practice Location | |||||||||
| Address1: | 171 ASHLEY AVE | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29425 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437921414 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2005 | ||||||||
| LastUpdateDate: | 02/18/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 217260 | MA | N | Allopathic & Osteopathic Physicians | Pediatrics | 2080P0202X | 52686 | SC | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Cardiology | 2080P0203X | 52686 | SC | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2014416 | 05 | MA | MEDICAID | 97288001 | 01 | MA | NETWORK HEALTH | OTHER | TUFTS HEALTH PLAN | 01 | MA | 217260 | OTHER | JC51504 | 05 | RI | MEDICAID | 25-01706 | 01 | MA | UNITED HEALTHCARE MA | OTHER | J26530 | 01 | MA | HMO BLUE | OTHER | 3253447 | 01 | MA | AETNA MA | OTHER | 26528 | 01 | MA | BMC HEALTHNET | OTHER | 32292 | 01 | MA | NEIGHBORHOOD HEALTH PLAN | OTHER | AA9211 | 01 | MA | HARVARD PILGRIM | OTHER | J26530 | 01 | MA | BCBS MA | OTHER | J26530 | 01 | MA | BLUE CARE ELECT | OTHER |