Healthcare Provider Details

I. General information

NPI: 1255380796
Provider Name (Legal Business Name): KENNETH MICHAEL GORNEY PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2006
Last Update Date: 05/12/2026
Certification Date: 05/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3681 OKEMOS RD STE 500
OKEMOS MI
48864-6923
US

IV. Provider business mailing address

5410 MARYLAND WAY STE 300
BRENTWOOD TN
37027-5339
US

V. Phone/Fax

Practice location:
  • Phone: 517-455-7600
  • Fax:
Mailing address:
  • Phone: 615-371-5744
  • Fax: 888-241-1404

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601006182
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6802076513
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: