Provider Demographics
NPI:1992997647
Name:ROBERGE, MATTHEW JOHN (MD)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:JOHN
Last Name:ROBERGE
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 1:100 MICHIGAN ST NE # MC845
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:212 S SULLIVAN AVE
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:MI
Practice Address - Zip Code:49412-1548
Practice Address - Country:US
Practice Address - Phone:616-391-3139
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-16
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301090883207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4301090883OtherSTATE LICENSE
MIMI7481009Medicare PIN