Provider Demographics
NPI:1841408697
Name:ETTIENNE'S PREMIER PEDIATRIC CARE LLC
Entity Type:Organization
Organization Name:ETTIENNE'S PREMIER PEDIATRIC CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SUZETTE
Authorized Official - Middle Name:SCIPIO
Authorized Official - Last Name:ETTIENNE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-390-7960
Mailing Address - Street 1:2905 MITCHELLVILLE RD
Mailing Address - Street 2:STE 115
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20716-1385
Mailing Address - Country:US
Mailing Address - Phone:301-390-7960
Mailing Address - Fax:301-218-2800
Practice Address - Street 1:2905 MITCHELLVILLE RD
Practice Address - Street 2:STE 115
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20716-1385
Practice Address - Country:US
Practice Address - Phone:301-390-7960
Practice Address - Fax:301-218-2800
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-17
Last Update Date:2013-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0046373208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD363101000Medicaid