Provider Demographics
NPI:1124364757
Name:ET FAMILY PRACTICE, INC.
Entity Type:Organization
Organization Name:ET FAMILY PRACTICE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ETA
Authorized Official - Middle Name:STEPHEN
Authorized Official - Last Name:TATAW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-982-7898
Mailing Address - Street 1:7231 HANOVER PKWY STE A
Mailing Address - Street 2:
Mailing Address - City:GREENBELT
Mailing Address - State:MD
Mailing Address - Zip Code:20770-2027
Mailing Address - Country:US
Mailing Address - Phone:301-982-7898
Mailing Address - Fax:301-982-2588
Practice Address - Street 1:7231 HANOVER PKWY STE A
Practice Address - Street 2:
Practice Address - City:GREENBELT
Practice Address - State:MD
Practice Address - Zip Code:20770-2027
Practice Address - Country:US
Practice Address - Phone:240-386-9682
Practice Address - Fax:301-477-7352
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-01
Last Update Date:2023-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR178223363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD337807100Medicaid
MD424652700Medicaid