Basic Information
| Provider Information | |||||||||
| NPI: | 1992701825 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CIVISTA MEDICAL CENTER INC. | ||||||||
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| 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: | 3016094474 | ||||||||
| FaxNumber: | 3016094411 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2005 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | ZANGER | ||||||||
| AuthorizedOfficialFirstName: | ALBERT | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 3016095163 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 05/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282NR1301X | MD | Y | Hospitals | General Acute Care Hospital | Rural |
ID Information
| ID | Type | State | Issuer | Description | 003355200 | 05 | MD | MEDICAID |