Provider Demographics
NPI:1063874659
Name:KEVIN C SORENSEN DPM PC
Entity type:Organization
Organization Name:KEVIN C SORENSEN DPM PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:C
Authorized Official - Last Name:SORENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:419-345-7867
Mailing Address - Street 1:44000 W 12 MILE RD
Mailing Address - Street 2:STE 111
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48377-2644
Mailing Address - Country:US
Mailing Address - Phone:248-347-8233
Mailing Address - Fax:
Practice Address - Street 1:44000 W 12 MILE RD
Practice Address - Street 2:STE 111
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48377-2644
Practice Address - Country:US
Practice Address - Phone:248-347-8233
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-23
Last Update Date:2016-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty