Provider Demographics
NPI:1689071219
Name:CIVISTA MEDICAL CENTER, INC.
Entity Type:Organization
Organization Name:CIVISTA MEDICAL CENTER, INC.
Other - Org Name:UNIVERSITY OF MARYLAND CHARLES REGIONAL REHABILITATION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF MEDICAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:MOSER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-609-4599
Mailing Address - Street 1:5 N LA PLATA CT STE 102
Mailing Address - Street 2:
Mailing Address - City:LA PLATA
Mailing Address - State:MD
Mailing Address - Zip Code:20646-5207
Mailing Address - Country:US
Mailing Address - Phone:301-609-4292
Mailing Address - Fax:
Practice Address - Street 1:5 N LA PLATA CT STE 102
Practice Address - Street 2:
Practice Address - City:LA PLATA
Practice Address - State:MD
Practice Address - Zip Code:20646-5207
Practice Address - Country:US
Practice Address - Phone:301-609-4292
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CIVISTA MEDICAL CENTER, INC. DBA UM CRMC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-11-25
Last Update Date:2021-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD225100000X, 225X00000X, 235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty