Provider Demographics
NPI:1457325532
Name:BRACKEN, MARK E (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:E
Last Name:BRACKEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41 MALL RD.
Mailing Address - Street 2:LAHEY CLINIC
Mailing Address - City:BURLINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:01805-0001
Mailing Address - Country:US
Mailing Address - Phone:781-744-8100
Mailing Address - Fax:781-744-5213
Practice Address - Street 1:41 MALL RD.
Practice Address - Street 2:LAHEY CLINIC
Practice Address - City:BURLINGTON
Practice Address - State:MA
Practice Address - Zip Code:01805-0001
Practice Address - Country:US
Practice Address - Phone:781-744-8100
Practice Address - Fax:781-744-5213
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2011-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA160536207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0130711Medicaid
MA110002578AMedicaid
MAA3235904Medicare PIN
MAA3235903Medicare PIN
MAA3235902Medicare PIN
MA110002578AMedicaid
MAA3235901Medicare PIN