Provider Demographics
NPI:1447450176
Name:CIVISTA CLINICAL SERVICES, L.L.C.
Entity type:Organization
Organization Name:CIVISTA CLINICAL SERVICES, L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SVP COO
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:HERBEK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-609-4141
Mailing Address - Street 1:PO BOX 1070
Mailing Address - Street 2:701 EAST CHARLES STREET
Mailing Address - City:LA PLATA
Mailing Address - State:MD
Mailing Address - Zip Code:20646-1070
Mailing Address - Country:US
Mailing Address - Phone:301-609-4000
Mailing Address - Fax:
Practice Address - Street 1:701 CHARLES ST
Practice Address - Street 2:
Practice Address - City:LA PLATA
Practice Address - State:MD
Practice Address - Zip Code:20646-5930
Practice Address - Country:US
Practice Address - Phone:301-609-4000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CIVISTA CARE PARTNERS, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-07-20
Last Update Date:2007-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty