Provider Demographics
NPI:1407120165
Name:KENNETH A BORENITSCH D O P C
Entity Type:Organization
Organization Name:KENNETH A BORENITSCH D O P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:ALBERT
Authorized Official - Last Name:BORENITSCH
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:231-723-8521
Mailing Address - Street 1:1237 E PARKDALE AVE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:MANISTEE
Mailing Address - State:MI
Mailing Address - Zip Code:49660-9353
Mailing Address - Country:US
Mailing Address - Phone:231-723-8521
Mailing Address - Fax:231-398-0478
Practice Address - Street 1:1237 E PARKDALE AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:MANISTEE
Practice Address - State:MI
Practice Address - Zip Code:49660-9353
Practice Address - Country:US
Practice Address - Phone:231-723-8521
Practice Address - Fax:231-398-0478
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-28
Last Update Date:2014-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101007441208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
015512665OtherBCBSM
MI1405970Medicaid
MI1405970Medicaid