Active NPI
Kacie Jo Costello Moody, PA
- Physician Assistant
- Fort Mill, SC
National Provider Identifier
1841461373
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Physician Assistant
- License
- 1295
- Practice address
- 704 Gold Hill Rd
Suite 1200
Fort Mill, SC 29715-8906 - Phone
- (704) 667-3380
- Fax
- (704) 667-3381
- NPI assigned
- Mar 12, 2008
- Last updated
- Jul 21, 2022
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 2
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Physician Assistant | 363A00000X | 0010-00779 | NC | |
| Physician Assistant | 363A00000X | 1295 | SC | Primary |
Addresses
Primary practice location
704 Gold Hill Rd
Suite 1200
Fort Mill, SC 29715-8906
Mailing address
PO Box 602148
Charlotte, NC 28260-2148
Phone (704) 667-3380
Other identifiers 2
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1841461373 | Medicaid | NC | |
| 0640PA | Medicaid | SC |
Other names 1
- Kacie Jo Costello
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in SC
- Eligible to order & refer
- Part B services: Yes
- Medical equipment: Yes
- Home health: Yes
- Power mobility devices: Yes
- Hospice: No
Enrollment records 1
Care Compare profile
Medicare Care Compare- Specialty
- Physician Assistant
- Education
- Medical University of South Carolina College of Medicine, 2006
- Medicare assignment
- Accepts the Medicare-approved amount as payment in full
- Group practices
Practice addresses (Care Compare)
354 Folly Rd
Suite 5
Charleston, SC 29412-2594
Phone (843) 225-2374
418 Folly Rd
Ab
Charleston, SC 29412-2625
Phone (843) 225-8320
5880 Rivers Ave
North Charleston, SC 29406-6053
Phone (843) 225-2374
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Physician Assistant
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 1295 | SC | MD | Athletic Trainer |
| 0010-00779 | NC | MD | Physician Assistant |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Medcare Urgent Care Center - Anderson LLC | Current | Accepting new patients | |
| Liberty Doctors LLC | Current | Accepting new patients | |
| Premier Clinics of Rock Hill | Past | Accepting new patients | |
| Premier Clinics PA | Past | Accepting new patients | |
| Premier Clinics of York | Past | Accepting new patients |
Locations
418 Folly Rd
#A
Charleston, SC 29412
Phone (843) 225-8320
8720 Dorchester Rd
North Charleston, SC 29420
Phone (843) 552-3629
8740 Rivers Ave
North Charleston, SC 29406
Phone (843) 337-2406
102 Harth Pl
Summerville, SC 29485
Phone (843) 832-6425
Interoperability endpoints
- kacie.costello@148186305331204.direct.elationemr.com
- kmoody@libertydoctors.ssdirect.aprima.com
Organizations & group practices 7
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.
-
dba Mackey Family Practice
- Family Medicine Physician
- Charleston, SC
- NPI 1700162203
-
dba Premier Medical
- Family Medicine Physician
- North Charleston, SC
- NPI 1992276091
-
dba Medcare Urgent Care
- Urgent Care Clinic/Center
- Charleston, SC
- NPI 1457579617
-
- Urgent Care Clinic/Center
- Anderson, SC
- NPI 1689004095
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1205280000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1658361600000",
"number": "1841461373",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "PO BOX 602148",
"city": "CHARLOTTE",
"state": "NC",
"postal_code": "282602148",
"telephone_number": "704-667-3380",
"fax_number": "704-667-3381"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "704 GOLD HILL RD",
"address_2": "SUITE 1200",
"city": "FORT MILL",
"state": "SC",
"postal_code": "297158906",
"telephone_number": "704-667-3380",
"fax_number": "704-667-3381"
}
],
"practiceLocations": [],
"basic": {
"last_name": "MOODY",
"first_name": "KACIE",
"middle_name": "JO COSTELLO",
"credential": "PA",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2008-03-12",
"last_updated": "2022-07-21",
"status": "A"
},
"taxonomies": [
{
"code": "363A00000X",
"taxonomy_group": "",
"desc": "Physician Assistant",
"state": "NC",
"license": "0010-00779",
"primary": false
},
{
"code": "363A00000X",
"taxonomy_group": "",
"desc": "Physician Assistant",
"state": "SC",
"license": "1295",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "1841461373",
"state": "NC"
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "0640PA",
"state": "SC"
}
],
"endpoints": [],
"other_names": [
{
"first_name": "KACIE",
"last_name": "COSTELLO",
"middle_name": "JO",
"credential": "PA",
"code": "1",
"type": "Former Name"
}
]
}Other providers in Fort Mill, SC
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 21, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
- Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.