MEDICARE: ETIENDEM RAY EBESOH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	374U00000X	Home Health Aide		DC
2	171M00000X	Case Manager/Care Coordinator

General Provider Information

NPI Number	:	1609746965
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ETIENDEM RAY EBESOH

Provider Business Mailing Address
First Line	:	2807 ORCHARD SUMMIT CT
Second Line	:
City	:	HYATTSVILLE
State	:	MD
Zip	:	20785-2621
Country	:	US
Telephone Number	:	240-615-1072
Fax Number	:

Provider Business Practice Location Address
First Line	:	2807 ORCHARD SUMMIT CT
Second Line	:
City	:	HYATTSVILLE
State	:	MD
Zip	:	20785-2621
Country	:	US
Telephone Number	:	240-615-1072
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/10/2025
Last Update Date	:	12/03/2025

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