Basic Information
| Provider Information | |||||||||
| NPI: | 1316914047 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | COSTA | ||||||||
| FirstName: | MARCO | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3605 WARRENSVILLE CENTER RD | ||||||||
| Address2: | 1ST FLOOR | ||||||||
| City: | SHAKER HEIGHTS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441225203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2162866295 | ||||||||
| FaxNumber: | 2162866341 | ||||||||
| Practice Location | |||||||||
| Address1: | 11100 EUCLID AVE | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441061716 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2168443800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/01/2006 | ||||||||
| LastUpdateDate: | 04/30/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | MFC1413 | FL | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RC0000X | 81-000076 | OH | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RC0000X | 81-000083 | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 000000539190 | 01 | OH | ANTHEM | OTHER | 000916022A | 05 | GA | MEDICAID | 7378305 | 01 | OH | AETNA | OTHER | 060068212 | 01 | FL | RAILROAD MEDICARE | OTHER | P00454327 | 01 | OH | RAILROAD MEDICARE | OTHER | 2621908-00 | 05 | FL | MEDICAID | 414956 | 01 | OH | WELLCARE | OTHER | 000000225199 | 01 | OH | UNISON | OTHER | 2770774 | 05 | OH | MEDICAID | 751122 | 01 | OH | BUCKEYE | OTHER |