Basic Information
| Provider Information | |||||||||
| NPI: | 1477758035 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SORENSEN | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | DPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1660 FEEHANVILLE DR STE 450 | ||||||||
| Address2: | |||||||||
| City: | MOUNT PROSPECT | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600566023 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8476274920 | ||||||||
| FaxNumber: | 8472996041 | ||||||||
| Practice Location | |||||||||
| Address1: | 10105 74TH ST STE 101 | ||||||||
| Address2: | |||||||||
| City: | KENOSHA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53142 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8473907666 | ||||||||
| FaxNumber: | 8473909345 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2007 | ||||||||
| LastUpdateDate: | 01/17/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | 016005622 | IL | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery | 213ES0103X | 929 | WI | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
ID Information
| ID | Type | State | Issuer | Description | 016005622 | 05 | IL | MEDICAID | 43242900 | 05 | WI | MEDICAID |