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General NPI Number Information
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NPI Number | 1619237344
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Entity Type | Organization
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Legal Business Name | CIVISTA CLINICAL SERCIVES, LLC
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Dates
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Enumeration Date | 05/29/2012
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Last Update Date | 06/12/2014
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Provider Practice Location Address
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Address Line | 101 CENTENNIAL ST SUITE B
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City | LA PLATA
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State | MD
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Zip | 20646-5975
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Country | US
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Telephone | 301-609-4539
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Fax |
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Provider Business Mailing Address
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Address Line | 75 REMITTANCE DR DEPT 6554
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City | CHICAGO
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State | IL
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Zip | 60675-6554
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Country | US
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Telephone | 301-609-4539
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Fax |
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Authorized Official
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Title or Position | PHYSICIAN RELATIONS SPECIALIST
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Name | STEPHANIE SIMM
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Credential |
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Telephone | 301-609-4539
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084N0400X
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Taxonomy Name | Neurology Physician
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License Number |
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License Number State |
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