Healthcare Provider Details

I. General information

NPI: 1659915171
Provider Name (Legal Business Name): AMANDA MARIE WILDERMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/29/2019
Last Update Date: 03/24/2023
Certification Date: 03/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 W DIANN LN
CARBONDALE IL
62901-5339
US

IV. Provider business mailing address

1268 COLE PLACE RD
CHESTER IL
62233-2054
US

V. Phone/Fax

Practice location:
  • Phone: 618-549-8006
  • Fax: 618-549-8434
Mailing address:
  • Phone: 618-210-7478
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number209.020318
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: