Basic Information
| Provider Information | |||||||||
| NPI: | 1194216101 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ETTA | ||||||||
| FirstName: | GINO | ||||||||
| MiddleName: | SHWKAT | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 27351 DEQUINDRE RD | ||||||||
| Address2: | |||||||||
| City: | MADISON HEIGHTS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480713487 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2489677661 | ||||||||
| FaxNumber: | 2489677876 | ||||||||
| Practice Location | |||||||||
| Address1: | 27351 DEQUINDRE RD | ||||||||
| Address2: | |||||||||
| City: | MADISON HEIGHTS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480713487 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2489677661 | ||||||||
| FaxNumber: | 2489677876 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2018 | ||||||||
| LastUpdateDate: | 11/04/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 4301501047 | MI | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 35.141973 | OH | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.