Provider Demographics
NPI:1710986047
Name:SORENSEN, KEVIN COURTNEY (DPM)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:COURTNEY
Last Name:SORENSEN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44000 W 12 MILE RD
Mailing Address - Street 2:SUITE111
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:248-347-8174
Practice Address - Street 1:44000 W 12 MILE RD
Practice Address - Street 2:SUITE111
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:248-347-8174
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2017-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36.003379213E00000X
MI5901002082213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH04618OtherPARAMOUNT
000000340879OtherANTHEM
OH2490193Medicaid
OHP00213362Medicare PIN
000000340879OtherANTHEM
OH0537250002Medicare NSC
OHSO4139952Medicare PIN
OH0537250003Medicare NSC
OHP00614561Medicare PIN
V00973Medicare UPIN
OH2490193Medicaid
OHSO4139951Medicare PIN