Basic Information
| Provider Information | |||||||||
| NPI: | 1952346025 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | COSTABELL | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | MARK | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 E LIBERTY ST STE 800 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402021428 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025874404 | ||||||||
| FaxNumber: | 5025874156 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 ABRAHAM FLEXNER WAY | ||||||||
| Address2: | ANESTHESIA DEPT | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402021818 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025874203 | ||||||||
| FaxNumber: | 5025874155 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2006 | ||||||||
| LastUpdateDate: | 04/05/2018 | ||||||||
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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 | 367500000X | 3004487 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 200510850 | 05 | IN | MEDICAID | 74010026 | 05 | KY | MEDICAID |