Basic Information
| Provider Information | |||||||||
| NPI: | 1245271709 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | COSTARELLA | ||||||||
| FirstName: | ADAM | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 821 KREHL AVE | ||||||||
| Address2: | |||||||||
| City: | GIRARD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 444201968 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1995 E STATE ST | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OH | ||||||||
| PostalCode: | 444602423 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3303321551 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 35038439C | OH | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0637949 | 05 | OH | MEDICAID | 942460636176 | 01 | OH | CARESOURCE | OTHER |