Healthcare Provider Details

I. General information

NPI: 1366269623
Provider Name (Legal Business Name): CIVISTA CLINICAL SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2024
Last Update Date: 09/26/2024
Certification Date: 09/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 CENTENNIAL ST STE E
LA PLATA MD
20646-5976
US

IV. Provider business mailing address

900 ELKRIDGE LANDING RD FL 2
LINTHICUM MD
21090-2924
US

V. Phone/Fax

Practice location:
  • Phone: 301-392-0525
  • Fax: 301-392-0458
Mailing address:
  • Phone: 443-462-5010
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ALBERT ZANGER
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 301-609-5163