Provider Demographics
NPI:1710247440
Name:CIVISTA CLINICAL SERVICES, LLC
Entity Type:Organization
Organization Name:CIVISTA CLINICAL SERVICES, LLC
Other - Org Name:LA PLATA SURGICAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN RELATIONS SPECIALIST
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 1:75 REMITTANCE DR DEPT 6554
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60675-6554
Mailing Address - Country:US
Mailing Address - Phone:301-609-4539
Mailing Address - Fax:
Practice Address - Street 1:500 CHARLES ST
Practice Address - Street 2:
Practice Address - City:LA PLATA
Practice Address - State:MD
Practice Address - Zip Code:20646-5931
Practice Address - Country:US
Practice Address - Phone:301-609-4539
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CIVISTA CLINICAL SERVICES, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-05-29
Last Update Date:2014-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty