Provider Demographics
NPI:1902984321
Name:CIVISTA PARTNERS AMBULATORY SURGERY CENTER
Entity Type:Organization
Organization Name:CIVISTA PARTNERS AMBULATORY SURGERY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF CLINICAL OPERATIONS
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCLURE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:240-427-1807
Mailing Address - Street 1:3510 OLD WASHINGTON RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20602-3233
Mailing Address - Country:US
Mailing Address - Phone:240-427-1800
Mailing Address - Fax:
Practice Address - Street 1:3510 OLD WASHINGTON RD
Practice Address - Street 2:SUITE 200
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20602-3233
Practice Address - Country:US
Practice Address - Phone:240-427-1800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2008-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA1303261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
105ZMedicare PIN