Basic Information
| Provider Information | |||||||||
| NPI: | 1710045505 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EMMERICH | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | II | ||||||||
| Credential: | P.T.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 202 S PARK ST | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 537151507 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6084176000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6408 COPPS AVE | ||||||||
| Address2: | |||||||||
| City: | MONONA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 537163702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6084173131 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2006 | ||||||||
| LastUpdateDate: | 01/11/2012 | ||||||||
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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 | 225200000X | 37019 | WI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
ID Information
| ID | Type | State | Issuer | Description | 1710045505 | 05 | WI | MEDICAID |