=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467177311
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EMERGE MEDSTAFFING LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/04/2022
-----------------------------------------------------
Last Update Date | 01/29/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 20180 S LAGRANGE RD
-----------------------------------------------------
City | FRANKFORT
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60423-3153
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 779-333-7965
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 20180 S LAGRANGE RD
-----------------------------------------------------
City | FRANKFORT
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60423-3153
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 779-333-7965
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/ CEO
-----------------------------------------------------
Name | RICHARD WATSON
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 708-887-8110
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------