Provider Demographics
NPI:1336900836
Name:ETA MEDICAL MANAGEMENT INC
Entity Type:Organization
Organization Name:ETA MEDICAL MANAGEMENT INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:MCDERMOTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-205-0030
Mailing Address - Street 1:5801 WOODSIDE AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:WOODSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11377-3437
Mailing Address - Country:US
Mailing Address - Phone:718-205-0030
Mailing Address - Fax:806-552-9573
Practice Address - Street 1:5801 WOODSIDE AVE STE 2
Practice Address - Street 2:
Practice Address - City:WOODSIDE
Practice Address - State:NY
Practice Address - Zip Code:11377-3437
Practice Address - Country:US
Practice Address - Phone:718-205-0030
Practice Address - Fax:806-552-9573
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-22
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty