Healthcare Provider Details

I. General information

NPI: 1710247440
Provider Name (Legal Business Name): CIVISTA CLINICAL SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/29/2012
Last Update Date: 06/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 CHARLES ST
LA PLATA MD
20646-5931
US

IV. Provider business mailing address

75 REMITTANCE DR DEPT 6554
CHICAGO IL
60675-6554
US

V. Phone/Fax

Practice location:
  • Phone: 301-609-4539
  • Fax:
Mailing address:
  • Phone: 301-609-4539
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

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