Healthcare Provider Details

I. General information

NPI: 1326021973
Provider Name (Legal Business Name): BRETT LEE STORM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/28/2005
Last Update Date: 01/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 FAIRVIEW AVE
DOTHAN AL
36301-3008
US

IV. Provider business mailing address

2015 ALEXANDER DR
DOTHAN AL
36301-3003
US

V. Phone/Fax

Practice location:
  • Phone: 334-793-9511
  • Fax: 334-794-0721
Mailing address:
  • Phone: 334-671-1696
  • Fax: 334-794-0721

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number26961
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number26961
License Number StateAL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier000532199F
Identifier TypeMEDICAID
Identifier StateGA
Identifier Issuer
# 2
Identifier009941386
Identifier TypeMEDICAID
Identifier StateAL
Identifier Issuer
# 3
Identifier009934243
Identifier TypeMEDICAID
Identifier StateAL
Identifier Issuer
# 4
Identifier370595101
Identifier TypeMEDICAID
Identifier StateFL
Identifier Issuer
# 5
Identifier009934244
Identifier TypeMEDICAID
Identifier StateAL
Identifier Issuer
# 6
Identifier009934246
Identifier TypeMEDICAID
Identifier StateAL
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: