Healthcare Provider Details

I. General information

NPI: 1568562106
Provider Name (Legal Business Name): ELIZABETH STORM MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2006
Last Update Date: 03/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 MARSHALL ST ACH #653
LITTLE ROCK AR
72202-3510
US

IV. Provider business mailing address

800 MARSHALL ST ACH #653
LITTLE ROCK AR
72202-3510
US

V. Phone/Fax

Practice location:
  • Phone: 501-364-1100
  • Fax: 501-603-1436
Mailing address:
  • Phone: 501-364-1100
  • Fax: 501-364-3480

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License NumberE-4880
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: