Basic Information
| Provider Information | |||||||||
| NPI: | 1013989177 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRAKORA | ||||||||
| FirstName: | MATHEW | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1560 E SHERMAN BLVD STE 240 | ||||||||
| Address2: | |||||||||
| City: | MUSKEGON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494441854 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2316723883 | ||||||||
| FaxNumber: | 2312316723 | ||||||||
| Practice Location | |||||||||
| Address1: | 1500 E SHERMAN BLVD | ||||||||
| Address2: | |||||||||
| City: | MUSKEGON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494441849 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2316723883 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/03/2006 | ||||||||
| LastUpdateDate: | 04/23/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 4301065022 | MI | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | 4301065022 | MI | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 104735165 | 05 | MI | MEDICAID | MB065022 | 01 | BCBS | OTHER |