Basic Information
| Provider Information | |||||||||
| NPI: | 1447450176 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CIVISTA CLINICAL SERVICES, L.L.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1070 | ||||||||
| Address2: | 701 EAST CHARLES STREET | ||||||||
| City: | LA PLATA | ||||||||
| State: | MD | ||||||||
| PostalCode: | 206461070 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3016094000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 701 CHARLES ST | ||||||||
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| City: | LA PLATA | ||||||||
| State: | MD | ||||||||
| PostalCode: | 206465930 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3016094000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2007 | ||||||||
| LastUpdateDate: | 07/20/2007 | ||||||||
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| AuthorizedOfficialLastName: | HERBEK | ||||||||
| AuthorizedOfficialFirstName: | GARY | ||||||||
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| AuthorizedOfficialTitleorPosition: | SVP COO | ||||||||
| AuthorizedOfficialTelephone: | 3016094141 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CIVISTA CARE PARTNERS, INC. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Hospitalist |
No ID Information.