Healthcare Provider Details

I. General information

NPI: 1841525540
Provider Name (Legal Business Name): CIVISTA PEDIATRIC HOSPITALIST GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/14/2009
Last Update Date: 10/22/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 GARRETT AVE
LA PLATA MD
20646-5960
US

IV. Provider business mailing address

5 GARRETT AVE PO BOX 1070
LA PLATA MD
20646-5960
US

V. Phone/Fax

Practice location:
  • Phone: 301-609-4000
  • Fax:
Mailing address:
  • Phone: 301-609-4000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. ERIK BOAS
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 301-609-4130