Healthcare Provider Details

I. General information

NPI: 1578615621
Provider Name (Legal Business Name): MARC THOMAS CIVITANO P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/17/2007
Last Update Date: 07/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 MAMARONECK AVE SUITE 101
HARRISON NY
10528-1635
US

IV. Provider business mailing address

600 MAMARONECK AVE SUITE 101
HARRISON NY
10528-1635
US

V. Phone/Fax

Practice location:
  • Phone: 914-686-0111
  • Fax: 914-686-8964
Mailing address:
  • Phone: 914-686-0111
  • Fax: 914-686-8964

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number011059
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: