Provider Demographics
NPI:1164689428
Name:BRAMLET, MATTHEW T (MD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:T
Last Name:BRAMLET
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:420 NE GLEN OAK AVE
Mailing Address - Street 2:SUITE 301
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61603-3105
Mailing Address - Country:US
Mailing Address - Phone:309-655-3453
Mailing Address - Fax:309-655-3410
Practice Address - Street 1:420 NE GLEN OAK AVE
Practice Address - Street 2:SUITE 301
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61603-3105
Practice Address - Country:US
Practice Address - Phone:309-655-3453
Practice Address - Fax:309-655-3410
Is Sole Proprietor?:No
Enumeration Date:2008-05-22
Last Update Date:2010-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-1233692080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL216946OtherMEDICARE GROUP PTAN
IL216946002Medicare PIN
IL209805087Medicare PIN
ILIL3270477Medicare PIN