Provider Demographics
NPI:1710950217
Name:EMILIA, EDGARDO S (MD)
Entity Type:Individual
Prefix:
First Name:EDGARDO
Middle Name:S
Last Name:EMILIA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1009 S 42ND ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-6218
Mailing Address - Country:US
Mailing Address - Phone:618-241-6015
Mailing Address - Fax:
Practice Address - Street 1:1009 S 42ND ST
Practice Address - Street 2:SUITE 1
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-6218
Practice Address - Country:US
Practice Address - Phone:618-241-6015
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-07
Last Update Date:2020-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-095710207P00000X
IL036095710207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036095710Medicaid
IL036095710Medicaid