Provider Demographics
NPI:1710045505
Name:EMMERICH, JOHN A II (PTA)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:A
Last Name:EMMERICH
Suffix:II
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 S PARK ST
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53715-1507
Mailing Address - Country:US
Mailing Address - Phone:608-417-6000
Mailing Address - Fax:
Practice Address - Street 1:6408 COPPS AVE
Practice Address - Street 2:
Practice Address - City:MONONA
Practice Address - State:WI
Practice Address - Zip Code:53716-3702
Practice Address - Country:US
Practice Address - Phone:608-417-3131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2012-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI37019225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1710045505Medicaid