Healthcare Provider Details

I. General information

NPI: 1801461926
Provider Name (Legal Business Name): CIVISTA MEDICAL CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/21/2021
Last Update Date: 05/21/2021
Certification Date: 05/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 GARRETT AVE
LA PLATA MD
20646-5960
US

IV. Provider business mailing address

PO BOX 1070
LA PLATA MD
20646-1070
US

V. Phone/Fax

Practice location:
  • Phone: 301-609-4000
  • Fax: 301-609-4411
Mailing address:
  • Phone: 301-609-5163
  • Fax: 301-934-0053

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State

VIII. Authorized Official

Name: ALBERT ZANGER
Title or Position: CFO
Credential:
Phone: 301-609-5163