Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2080P0202X | Pediatric Cardiologist | 036-123369 | IL |
NPI | 1164689428 |
---|---|
Provider Name | Dr. Matthew T Bramlet |
First Address | Peoria, IL 61603-3105 |
Second Address | Peoria, IL 61603-3105 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 22/05/2008 |
Last Update Date | 27/12/2010 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
216946 | MEDICARE GROUP PTAN (01) | IL |