1730252594 NPI number — SUZETTE SCIPIO - ETTIENNE MD

Table of content: SUZETTE SCIPIO - ETTIENNE MD (NPI 1730252594)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730252594 NPI number — SUZETTE SCIPIO - ETTIENNE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SCIPIO - ETTIENNE
Provider First Name:
SUZETTE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ETTIENNE
Provider Other First Name:
SUZETTE
Provider Other Middle Name:
SCIPIO
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1730252594
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/11/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2905 MITCHELLVILLE RD
Provider Second Line Business Mailing Address:
STE 115
Provider Business Mailing Address City Name:
BOWIE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20716-1385
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-390-7960
Provider Business Mailing Address Fax Number:
301-218-2800

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2905 MITCHELLVILLE RD
Provider Second Line Business Practice Location Address:
STE 115
Provider Business Practice Location Address City Name:
BOWIE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20716-1385
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-390-7960
Provider Business Practice Location Address Fax Number:
301-218-2800
Provider Enumeration Date:
11/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  D0046373 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 363101000 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




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