Basic Information
| Provider Information | |||||||||
| NPI: | 1841525540 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CIVISTA PEDIATRIC HOSPITALIST GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5 GARRETT AVE | ||||||||
| Address2: | PO BOX 1070 | ||||||||
| City: | LA PLATA | ||||||||
| State: | MD | ||||||||
| PostalCode: | 206465960 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3016094000 | ||||||||
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| Address1: | 5 GARRETT AVE | ||||||||
| Address2: | |||||||||
| City: | LA PLATA | ||||||||
| State: | MD | ||||||||
| PostalCode: | 206465960 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3016094000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/14/2009 | ||||||||
| LastUpdateDate: | 10/22/2009 | ||||||||
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| AuthorizedOfficialLastName: | BOAS | ||||||||
| AuthorizedOfficialFirstName: | ERIK | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 3016094130 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CIVISTA MEDICAL CENTER | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.