Basic Information
| Provider Information | |||||||||
| NPI: | 1558441394 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | URETA | ||||||||
| FirstName: | EMERITO | ||||||||
| MiddleName: | FERNANDEZ | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 400 N CALDWELL ST | ||||||||
| Address2: | |||||||||
| City: | STAUNTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620881499 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6186352200 | ||||||||
| FaxNumber: | 6186354244 | ||||||||
| Practice Location | |||||||||
| Address1: | 325 N CALDWELL ST | ||||||||
| Address2: | |||||||||
| City: | STAUNTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620881421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6186352221 | ||||||||
| FaxNumber: | 6186352269 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/16/2006 | ||||||||
| LastUpdateDate: | 10/24/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 036045117 | IL | N | Allopathic & Osteopathic Physicians | Surgery | 208D00000X | 036045117 | IL | N | Allopathic & Osteopathic Physicians | General Practice | 207Q00000X | 036045117 | IL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036045117 | 05 | IL | MEDICAID |