1720022742 NPI number — MICHAEL DEAN SORENSEN M.D.

Table of content: MICHAEL DEAN SORENSEN M.D. (NPI 1720022742)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720022742 NPI number — MICHAEL DEAN SORENSEN M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SORENSEN
Provider First Name:
MICHAEL
Provider Middle Name:
DEAN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1720022742
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/08/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2234 COLONIAL BLVD
Provider Second Line Business Mailing Address:
ATTN: PAYER CONTRACTING AND RELATIONS
Provider Business Mailing Address City Name:
FORT MYERS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33907-1412
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
239-931-7342
Provider Business Mailing Address Fax Number:
239-931-7385

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
212 SMITH CHURCH RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROANOKE RAPIDS
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27870-4914
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
252-537-1717
Provider Business Practice Location Address Fax Number:
252-537-1366
Provider Enumeration Date:
06/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2085R0001X , with the licence number:  9801068 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2085R0001X , with the licence number: C1-0006356 , registered in the state of DE ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0001X , with the licence number: D0057941 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1720022742 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0001154001 , issued by the state of ( DE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 920006532 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( DE ) . This identifiers is of the category "OTHER".
  • Identifier: 300402300 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




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