1205897956 NPI number — MR. RICHARD JAMES STORK MD

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205897956 NPI number — MR. RICHARD JAMES STORK MD

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

STORK

Provider First Name:

RICHARD

Provider Middle Name:

JAMES

Provider Name Prefix Text:

MR.

Provider Name Suffix Text:

Provider Credential Text:

MD

Provider Gender Code:

M

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:

1205897956

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

01/14/2014

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

PO BOX 1267

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

MOUNT AIRY

Provider Business Mailing Address State Name:

NC

Provider Business Mailing Address Postal Code:

27030-1267

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

336-786-4522

Provider Business Mailing Address Fax Number:

336-789-3025

Provider First Line Business Practice Location Address:

110 DUTCHMAN CT

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:

ELKIN

Provider Business Practice Location Address State Name:

NC

Provider Business Practice Location Address Postal Code:

28621-2237

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

336-835-5330

Provider Business Practice Location Address Fax Number:

336-835-5337

Provider Enumeration Date:

03/31/2006

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 208VP0000X , with the licence number:  MD0000021916 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 208VP0000X , with the licence number: 047537 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 208VP0000X , with the licence number: 2007-00624 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 208VP0000X , with the licence number: 2008006962 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 208VP0014X , with the licence number: 2008006962 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 000834666M , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
• Identifier: 018XV . This is a "BCBS OF NC" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
• Identifier: 197955 . This is a "MEDCOST" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
• Identifier: 3893809 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
• Identifier: 009976335 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
• Identifier: 5906657 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
• Identifier: 113000001 . This is a "MEDICARE PTAN" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".