Provider Demographics
NPI:1396748331
Name:SORENSEN, MICHAEL J (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:SORENSEN
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 1:1223 WILLOW CREEK RD
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86301-1427
Mailing Address - Country:US
Mailing Address - Phone:928-777-9950
Mailing Address - Fax:928-777-9975
Practice Address - Street 1:1223 WILLOW CREEK RD
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-1427
Practice Address - Country:US
Practice Address - Phone:928-777-9950
Practice Address - Fax:928-777-9975
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2022-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ604572081P2900X, 208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3371161Medicaid
TN3825983Medicaid
TN620819926OtherTRICARE
TN620819926OtherCIGNA
TN12608OtherTLC
AR135333001Medicaid
TN250009146OtherRAILROAD MEDICARE
MS620819926OtherBCBS
TN1255827OtherCIGNA
TN3091702OtherBLUE CROSS
MS000120000Medicaid
TN620819926OtherAETNA
AR110318002Medicaid
TN5015681OtherAETNA
MS7187860Medicaid
TNE47051Medicare UPIN
TN620819926OtherTRICARE
MS7187860Medicaid