Provider Demographics
NPI:1679955736
Name:ANN R COSTELLO MD
Entity type:Organization
Organization Name:ANN R COSTELLO MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANN
Authorized Official - Middle Name:R
Authorized Official - Last Name:COSTELLO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:607-273-2811
Mailing Address - Street 1:217 N AURORA ST
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-4345
Mailing Address - Country:US
Mailing Address - Phone:607-273-2811
Mailing Address - Fax:607-273-1170
Practice Address - Street 1:217 N AURORA ST
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-4345
Practice Address - Country:US
Practice Address - Phone:607-273-2811
Practice Address - Fax:607-273-1170
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-25
Last Update Date:2015-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF338797-1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYF338797-1OtherSTATE LICENSE