Provider Demographics
NPI:1992852685
Name:BORENITSCH, KENNETH ALBERT (DO)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:ALBERT
Last Name:BORENITSCH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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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
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2014-02-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5101007441208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI015512665OtherBLUE CROSS BLUE SHIELD OF MI
MI1405970Medicaid
MI1405970Medicaid
B44360Medicare UPIN