Healthcare Provider Details

I. General information

NPI: 1285740571
Provider Name (Legal Business Name): MARK EMENECKER D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2006
Last Update Date: 04/15/2021
Certification Date: 04/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

116 W BUCHANAN AVE
CHARLESTON IL
61920-2522
US

IV. Provider business mailing address

1005 HEALTH CENTER DR STE 201
MATTOON IL
61938-4693
US

V. Phone/Fax

Practice location:
  • Phone: 217-345-7700
  • Fax: 217-345-7200
Mailing address:
  • Phone: 217-238-6055
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036-104851
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: