Provider Demographics
NPI:1467904789
Name:ECKERSTROM, EMILY N (MD)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:N
Last Name:ECKERSTROM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:EMILY
Other - Middle Name:N
Other - Last Name:EHARDT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:849 KELLOGG AVE
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53546-2808
Mailing Address - Country:US
Mailing Address - Phone:608-755-7960
Mailing Address - Fax:608-755-7873
Practice Address - Street 1:7702 N ALPINE RD
Practice Address - Street 2:
Practice Address - City:LOVES PARK
Practice Address - State:IL
Practice Address - Zip Code:61111-3107
Practice Address - Country:US
Practice Address - Phone:815-971-2000
Practice Address - Fax:815-971-9266
Is Sole Proprietor?:No
Enumeration Date:2016-11-03
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI66088-20390200000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program