Basic Information
| Provider Information | |||||||||
| NPI: | 1316967284 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILSON-COSTELLO | ||||||||
| FirstName: | DEANNE | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3605 WARRENSVILLE CENTER RD | ||||||||
| Address2: | |||||||||
| City: | SHAKER HTS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441225203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2162866299 | ||||||||
| FaxNumber: | 2162866341 | ||||||||
| Practice Location | |||||||||
| Address1: | 11100 EUCLID AVE | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441061716 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2168447700 | ||||||||
| FaxNumber: | 2162866341 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2006 | ||||||||
| LastUpdateDate: | 06/12/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 35-067001 | OH | N | Allopathic & Osteopathic Physicians | Anesthesiology | 2080N0001X | 35-067001 | OH | Y | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine | 207LP3000X | 35-067001 | OH | N | Allopathic & Osteopathic Physicians | Anesthesiology | Pediatric Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 000000027353 | 01 | OH | ANTHEM | OTHER | 000000526173 | 01 | OH | ANTHEM | OTHER | 000000221190 | 01 | OH | UINISON | OTHER | 0019347280001 | 05 | PA | MEDICAID | 745987 | 01 | OH | BUCKEYE | OTHER | 0187444 | 01 | OH | BCMH | OTHER | 0658025 | 01 | OH | AETNA | OTHER | 364141 | 01 | OH | WELLCARE | OTHER | 0187444 | 05 | OH | MEDICAID | 1019347280001 | 01 | PA | PENNSLYVANIA MEDICAID | OTHER |