Provider Demographics
NPI:1841525540
Name:CIVISTA PEDIATRIC HOSPITALIST GROUP
Entity type:Organization
Organization Name:CIVISTA PEDIATRIC HOSPITALIST GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:ERIK
Authorized Official - Middle Name:
Authorized Official - Last Name:BOAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-609-4130
Mailing Address - Street 1:5 GARRETT AVE
Mailing Address - Street 2:PO BOX 1070
Mailing Address - City:LA PLATA
Mailing Address - State:MD
Mailing Address - Zip Code:20646-5960
Mailing Address - Country:US
Mailing Address - Phone:301-609-4000
Mailing Address - Fax:
Practice Address - Street 1:5 GARRETT AVE
Practice Address - Street 2:
Practice Address - City:LA PLATA
Practice Address - State:MD
Practice Address - Zip Code:20646-5960
Practice Address - Country:US
Practice Address - Phone:301-609-4000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CIVISTA MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-10-14
Last Update Date:2009-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty