Provider Demographics
NPI:1689212151
Name:CIVISTA CLINICAL SERVICES, LLC
Entity Type:Organization
Organization Name:CIVISTA CLINICAL SERVICES, LLC
Other - Org Name:UM CHARLES REGIONAL ENDOSCOPY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:ALBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:ZANGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-609-5163
Mailing Address - Street 1:5 N LA PLATA CT STE 201
Mailing Address - Street 2:
Mailing Address - City:LA PLATA
Mailing Address - State:MD
Mailing Address - Zip Code:20646-5208
Mailing Address - Country:US
Mailing Address - Phone:301-609-5080
Mailing Address - Fax:
Practice Address - Street 1:5 N LA PLATA CT STE 201
Practice Address - Street 2:
Practice Address - City:LA PLATA
Practice Address - State:MD
Practice Address - Zip Code:20646-5208
Practice Address - Country:US
Practice Address - Phone:301-609-4000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CIVISTA CLINICAL SERVICES, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-12-16
Last Update Date:2020-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0800XAmbulatory Health Care FacilitiesClinic/CenterEndoscopy