Individual
MICHAEL JOHN COSTELLO
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PT
Contact information
Practice address
310 TAUGHANNOCK BLVD, ITHACA, NY 14850-3251
(607) 252-3500
(607) 252-3505
Mailing address
310 TAUGHANNOCK BLVD, ITHACA, NY 14850-3251
(607) 252-3500
(607) 252-3505
Taxonomy
Speciality
Code
Description
License number
State
2251X0800X
Orthopedic Physical Therapist
Primary
017819-1
NY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
00332729
—
NY
01
—
22-2325405
EMPLOYER FEDERAL TAX IDENTIFICATION CAYUGA MEDICAL CENTER AT ITHACA
NY
Enumeration date
03/10/2010
Last updated
03/10/2010
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