Provider Demographics
NPI:1205035805
Name:CIVISTA CLINICAL SERVICES, LLC
Entity Type:Organization
Organization Name:CIVISTA CLINICAL SERVICES, LLC
Other - Org Name:UNIVERSITY OF MARYLAND CHARLES REGIONAL OB/GYN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN RELATIONS SPECIALISTS
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:SIMM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-609-4539
Mailing Address - Street 1:605 EAST CHARLES STREET
Mailing Address - Street 2:
Mailing Address - City:LA PLATA
Mailing Address - State:MD
Mailing Address - Zip Code:20646
Mailing Address - Country:US
Mailing Address - Phone:301-609-4800
Mailing Address - Fax:301-609-5220
Practice Address - Street 1:605 EAST CHARLES STREET
Practice Address - Street 2:
Practice Address - City:LA PLATA
Practice Address - State:MD
Practice Address - Zip Code:20646
Practice Address - Country:US
Practice Address - Phone:301-609-4800
Practice Address - Fax:301-609-5220
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CIVISTA CLINICAL SERVICES, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-07-13
Last Update Date:2015-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty