Basic Information
| Provider Information | |||||||||
| NPI: | 1578627139 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EMERY | ||||||||
| FirstName: | ROBERT | ||||||||
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| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | N6520 GUY ROAD | ||||||||
| Address2: | HO-CHUNK HEALTH CARE CENTER | ||||||||
| City: | BLACK RIVER FALLS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 54615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7152849851 | ||||||||
| FaxNumber: | 7152845150 | ||||||||
| Practice Location | |||||||||
| Address1: | HO-CHUNK HEALTH CARE CENTER | ||||||||
| Address2: | N6520 GUY ROAD | ||||||||
| City: | BLACK RIVER FALLS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 54615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7152849851 | ||||||||
| FaxNumber: | 7152845107 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/20/2006 | ||||||||
| LastUpdateDate: | 03/14/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 1683 | MN | N | Eye and Vision Services Providers | Optometrist | 152W00000X | 1577-035 | WI | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 38506900 | 05 | WI | MEDICAID | 514523600 | 05 | MN | MEDICAID |