Provider Demographics
NPI:1871719476
Name:CHERYL EMMONS MDSC
Entity type:Organization
Organization Name:CHERYL EMMONS MDSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:
Authorized Official - Last Name:EMMONS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-244-5053
Mailing Address - Street 1:1100 S 42ND ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-6216
Mailing Address - Country:US
Mailing Address - Phone:618-244-5053
Mailing Address - Fax:618-244-1355
Practice Address - Street 1:1100 S 42ND ST
Practice Address - Street 2:SUITE B
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-6216
Practice Address - Country:US
Practice Address - Phone:618-244-5053
Practice Address - Fax:618-244-1355
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL4132016OtherBCBS OF IL
IL3485401763Medicaid
IL204074Medicare ID - Type Unspecified
IL3485401763Medicaid