Basic Information
Provider Information | |||||||||
NPI: | 1588952295 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SORENSEN | ||||||||
FirstName: | SCOTT | ||||||||
MiddleName: | NEVINS | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5841 S MARYLAND AVE | ||||||||
Address2: | NEURORADIOLOGY M/C 2026 | ||||||||
City: | CHICAGO | ||||||||
State: | IL | ||||||||
PostalCode: | 606371447 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7343557293 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 25 MICHIGAN ST NE | ||||||||
Address2: | SUITE 2200 | ||||||||
City: | GRAND RAPIDS | ||||||||
State: | MI | ||||||||
PostalCode: | 495032515 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6163913245 | ||||||||
FaxNumber: | 6163913130 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/14/2011 | ||||||||
LastUpdateDate: | 07/06/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X |   |   | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   | 2085R0202X | 4301099196 | MI | N |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085D0003X | 336101630 | IL | Y |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Neuroimaging |
No ID Information.