MEDICARE: JOHN T EMMERT OD PC

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	152W00000X	Optometrist		IL

General Provider Information

NPI Number	:	1245414994
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JOHN T EMMERT OD PC

Provider Business Mailing Address
First Line	:	1029 LASALLE ST.
Second Line	:
City	:	OTTAWA
State	:	IL
Zip	:	61350-2018
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1029 LASALLE ST.
Second Line	:
City	:	OTTAWA
State	:	IL
Zip	:	61350-2018
Country	:	US
Telephone Number	:	815-433-4100
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	JOHN T EMMERT
Credential	:	O.D.
Telephone Number	:	815-433-4100

Provider Enumeration Date	:	12/18/2007
Last Update Date	:	04/04/2008

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