Basic Information
| Provider Information | |||||||||
| NPI: | 1285740571 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EMENECKER | ||||||||
| FirstName: | MARK | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1005 HEALTH CENTER DR STE 201 | ||||||||
| Address2: | |||||||||
| City: | MATTOON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 619384693 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2172386055 | ||||||||
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| Practice Location | |||||||||
| Address1: | 116 W BUCHANAN AVE | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 619202522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173457700 | ||||||||
| FaxNumber: | 2173457200 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2006 | ||||||||
| LastUpdateDate: | 04/15/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 036-104851 | IL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.