Provider Demographics
NPI:1780744987
Name:SORUM, SCOT L (DC)
Entity type:Individual
Prefix:
First Name:SCOT
Middle Name:L
Last Name:SORUM
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:506 N. LEXINGTON PKWY
Mailing Address - Street 2:
Mailing Address - City:ST. PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104
Mailing Address - Country:US
Mailing Address - Phone:651-224-1921
Mailing Address - Fax:651-224-1936
Practice Address - Street 1:506 LEXINGTON PKWY N
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-4644
Practice Address - Country:US
Practice Address - Phone:651-224-1921
Practice Address - Fax:651-224-1936
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3639111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN9746871Medicaid
MN9746871Medicaid