1457332454 NPI number — BRADLEY W STORM MD

Employer Identification Number (EIN)	:
Provider Organization Name (Legal Business Name)	:
Provider Last Name (Legal Name)	:	STORM
Provider First Name	:	BRADLEY
Provider Middle Name	:	W
Provider Name Prefix Text	:
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	:	1457332454
Entity Type Code	:	Individual
Replacement NPI	:
Last Update Date	:	07/08/2007
NPI Deactivation Reason Code	:
NPI Deactivation Date	:	11/08/2005
NPI Reactivation Date	:	11/17/2006

Provider First Line Business Mailing Address	:	20375 W 151ST ST
Provider Second Line Business Mailing Address	:	SUITE 370
Provider Business Mailing Address City Name	:	OLATHE
Provider Business Mailing Address State Name	:	KS
Provider Business Mailing Address Postal Code	:	66061
Provider Business Mailing Address Country Code	:	US
Provider Business Mailing Address Telephone Number	:	9137820707
Provider Business Mailing Address Fax Number	:	9137825813

Provider First Line Business Practice Location Address	:	20375 W 151ST ST #370
Provider Second Line Business Practice Location Address	:	PREMIER PLASTIC SURGERY
Provider Business Practice Location Address City Name	:	OLATHE
Provider Business Practice Location Address State Name	:	KS
Provider Business Practice Location Address Postal Code	:	66061
Provider Business Practice Location Address Country Code	:	US
Provider Business Practice Location Address Telephone Number	:	9137820707
Provider Business Practice Location Address Fax Number	:	9137825813
Provider Enumeration Date	:	11/08/2005

Authorized Official Last Name	:
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• Taxonomy code: 2086S0122X , with the licence number:  0423438 , registered in the state of KS .
• Taxonomy code: 2086S0105X , with the licence number: 0423438 , registered in the state of KS .

• Identifier: 1308048 . This is a "UNITED HEALTH CARE" identifier , issued by the state of ( KS ) . This identifiers is of the category "".
• Identifier: 16274034 . This is a "BLUE CROSS" identifier , issued by the state of ( KS ) . This identifiers is of the category "".
• Identifier: 10012005A , issued by the state of ( KS ) . This identifiers is of the category "".
• Identifier: A071699 , issued by the state of ( KS ) . This identifiers is of the category "".
• Identifier: E59309 . This identifiers is of the category "".