Provider Demographics
NPI:1477597987
Name:JOSEPH, EMMANUELLA (MD)
Entity Type:Individual
Prefix:
First Name:EMMANUELLA
Middle Name:
Last Name:JOSEPH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2077
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62524-2077
Mailing Address - Country:US
Mailing Address - Phone:217-876-9987
Mailing Address - Fax:217-876-1792
Practice Address - Street 1:600 S 13TH ST
Practice Address - Street 2:SUITE M
Practice Address - City:PEKIN
Practice Address - State:IL
Practice Address - Zip Code:61554-4936
Practice Address - Country:US
Practice Address - Phone:309-346-8038
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2008-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL09015685OtherBLUE CROSS BLUE SHIELD
IL09015685OtherBLUE CROSS BLUE SHIELD
ILK28112Medicare PIN