Healthcare Provider Details

I. General information

NPI: 1467904789
Provider Name (Legal Business Name): EMILY N. ECKERSTROM MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: EMILY N. EHARDT

II. Dates (important events)

Enumeration Date: 11/03/2016
Last Update Date: 04/13/2026
Certification Date: 04/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7702 N ALPINE RD
LOVES PARK IL
61111-3107
US

IV. Provider business mailing address

849 KELLOGG AVE
JANESVILLE WI
53546-2808
US

V. Phone/Fax

Practice location:
  • Phone: 815-971-2000
  • Fax: 815-971-9266
Mailing address:
  • Phone: 608-755-7960
  • Fax: 608-755-7873

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number66088-20
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: