Basic Information
Provider Information | |||||||||
NPI: | 1346682291 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | COSTA HENNIS | ||||||||
FirstName: | PRIYANKA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 8055 MAYFIELD RD | ||||||||
Address2: | STE 105 | ||||||||
City: | CHESTERLAND | ||||||||
State: | OH | ||||||||
PostalCode: | 440262447 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4402148027 | ||||||||
FaxNumber: | 2162018173 | ||||||||
Practice Location | |||||||||
Address1: | 500 LAUCHWOOD DR | ||||||||
Address2: |   | ||||||||
City: | LAURINBURG | ||||||||
State: | NC | ||||||||
PostalCode: | 283525501 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9102916904 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/20/2013 | ||||||||
LastUpdateDate: | 09/26/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | 35136107 | OH | Y |   | Allopathic & Osteopathic Physicians | Hospitalist |   | 208M00000X | 2016-01798 | NC | N |   | Allopathic & Osteopathic Physicians | Hospitalist |   |
No ID Information.