Provider Demographics
NPI:1407293426
Name:COSTELLO, BRIANA TERESA (MD)
Entity type:Individual
Prefix:
First Name:BRIANA
Middle Name:TERESA
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1819 CLINCH AVE STE 108
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37916-2435
Mailing Address - Country:US
Mailing Address - Phone:865-546-5111
Mailing Address - Fax:
Practice Address - Street 1:1819 CLINCH AVE STE 108
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37916-2435
Practice Address - Country:US
Practice Address - Phone:865-546-5111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-31
Last Update Date:2024-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN69990207RC0000X, 207RI0011X
TXBP10055271207RC0000X
TXS0273207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ093025Medicaid