Basic Information
Provider Information | |||||||||
NPI: | 1801461926 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CIVISTA MEDICAL CENTER, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1070 | ||||||||
Address2: |   | ||||||||
City: | LA PLATA | ||||||||
State: | MD | ||||||||
PostalCode: | 206461070 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3016095163 | ||||||||
FaxNumber: | 3019340053 | ||||||||
Practice Location | |||||||||
Address1: | 5 GARRETT AVE | ||||||||
Address2: |   | ||||||||
City: | LA PLATA | ||||||||
State: | MD | ||||||||
PostalCode: | 206465960 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3016094000 | ||||||||
FaxNumber: | 3016094411 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/21/2021 | ||||||||
LastUpdateDate: | 05/21/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ZANGER | ||||||||
AuthorizedOfficialFirstName: | ALBERT | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CFO | ||||||||
AuthorizedOfficialTelephone: | 3016095163 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/21/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X |   |   | Y |   | Laboratories | Clinical Medical Laboratory |   |
No ID Information.