Healthcare Provider Details

I. General information

NPI: 1205035805
Provider Name (Legal Business Name): CIVISTA CLINICAL SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2007
Last Update Date: 05/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

605 EAST CHARLES STREET
LA PLATA MD
20646
US

IV. Provider business mailing address

605 EAST CHARLES STREET
LA PLATA MD
20646
US

V. Phone/Fax

Practice location:
  • Phone: 301-609-4800
  • Fax: 301-609-5220
Mailing address:
  • Phone: 301-609-4800
  • Fax: 301-609-5220

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State

VIII. Authorized Official

Name: STEPHANIE SIMM
Title or Position: PHYSICIAN RELATIONS SPECIALISTS
Credential:
Phone: 301-609-4539