Healthcare Provider Details

I. General information

NPI: 1558441394
Provider Name (Legal Business Name): EMERITO FERNANDEZ URETA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/16/2006
Last Update Date: 10/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 N CALDWELL ST
STAUNTON IL
62088-1421
US

IV. Provider business mailing address

400 N CALDWELL ST
STAUNTON IL
62088-1499
US

V. Phone/Fax

Practice location:
  • Phone: 618-635-2221
  • Fax: 618-635-2269
Mailing address:
  • Phone: 618-635-2200
  • Fax: 618-635-4244

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number036045117
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number036045117
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036045117
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: