Provider Demographics
NPI:1689994014
Name:BRAMHAM, AMANDA M (MD)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:M
Last Name:BRAMHAM
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 1:1005 HEALTH CENTER DR STE 201
Mailing Address - Street 2:
Mailing Address - City:MATTOON
Mailing Address - State:IL
Mailing Address - Zip Code:61938-4693
Mailing Address - Country:US
Mailing Address - Phone:217-238-6055
Mailing Address - Fax:
Practice Address - Street 1:200 RICHMOND AVE E
Practice Address - Street 2:
Practice Address - City:MATTOON
Practice Address - State:IL
Practice Address - Zip Code:61938-4652
Practice Address - Country:US
Practice Address - Phone:217-234-7000
Practice Address - Fax:217-234-7011
Is Sole Proprietor?:No
Enumeration Date:2010-06-08
Last Update Date:2024-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI101592207Q00000X
WI83732-20207Q00000X
IL036-133693207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1689994014Medicaid