Provider Demographics
NPI:1215595582
Name:BRANDT, MARY CATHERINE (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:CATHERINE
Last Name:BRANDT
Suffix:
Gender:F
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:PO BOX 19638
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62794-9638
Mailing Address - Country:US
Mailing Address - Phone:217-545-4401
Mailing Address - Fax:217-545-1793
Practice Address - Street 1:701 N 1ST ST STE D308
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-3757
Practice Address - Country:US
Practice Address - Phone:217-545-4401
Practice Address - Fax:217-545-1793
Is Sole Proprietor?:No
Enumeration Date:2019-06-03
Last Update Date:2019-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125074038208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery