Basic Information
| Provider Information | |||||||||
| NPI: | 1598856858 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | COSTARINO | ||||||||
| FirstName: | ANDREW | ||||||||
| MiddleName: | T. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 E PENN SQUARE | ||||||||
| Address2: | WANAMAKER BLDG., 9TH FL, N | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191040001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2674259320 | ||||||||
| FaxNumber: | 2674259331 | ||||||||
| Practice Location | |||||||||
| Address1: | 3401 CIVIC CENTER BLVD STE 9329 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191044319 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2155901858 | ||||||||
| FaxNumber: | 2674259331 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2006 | ||||||||
| LastUpdateDate: | 06/15/2018 | ||||||||
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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 | 207L00000X | C10006289 | DE | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207LP3000X | C10006289 | DE | N | Allopathic & Osteopathic Physicians | Anesthesiology | Pediatric Anesthesiology | 2080P0203X | C10006289 | DE | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | 496804 | 05 | NJ | MEDICAID | 2835100 | 05 | MD | MEDICAID | 6736441 | 05 | VA | MEDICAID | 1642039 | 05 | NY | MEDICAID | 7611115 | 05 | NC | MEDICAID | 963171 | 05 | PA | MEDICAID | Q4937E | 05 | SC | MEDICAID | 410070 | 05 | DC | MEDICAID |