Provider Demographics
NPI:1194803353
Name:CHRISTOPHER P COSTA MD PC
Entity type:Organization
Organization Name:CHRISTOPHER P COSTA MD PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:P
Authorized Official - Last Name:COSTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:308-537-2222
Mailing Address - Street 1:514 9TH STREET
Mailing Address - Street 2:
Mailing Address - City:GOTHENBURG
Mailing Address - State:NE
Mailing Address - Zip Code:69138-1917
Mailing Address - Country:US
Mailing Address - Phone:308-537-2222
Mailing Address - Fax:308-537-2960
Practice Address - Street 1:514 9TH STREET
Practice Address - Street 2:
Practice Address - City:GOTHENBURG
Practice Address - State:NE
Practice Address - Zip Code:69138-1917
Practice Address - Country:US
Practice Address - Phone:308-537-2222
Practice Address - Fax:308-537-2960
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2007-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE20028207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025207300OtherRURAL HEALTH MEDICAID
283850OtherRIVERBEND
NE10025207400Medicaid
283850OtherRIVERBEND
G25250Medicare UPIN