Healthcare Provider Details

I. General information

NPI: 1457332454
Provider Name (Legal Business Name): BRADLEY W STORM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2005
Last Update Date: 08/03/2011
Certification Date:
Deactivation Date: 11/08/2005
Reactivation Date: 11/17/2006

III. Provider practice location address

20375 W 151ST ST #370 PREMIER PLASTIC SURGERY
OLATHE KS
66061
US

IV. Provider business mailing address

20375 W 151ST ST SUITE 370
OLATHE KS
66061
US

V. Phone/Fax

Practice location:
  • Phone: 913-782-0707
  • Fax: 913-782-5813
Mailing address:
  • Phone: 913-782-0707
  • Fax: 913-782-5813

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0105X
TaxonomySurgery of the Hand (Surgery) Physician
License Number0423438
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number0423438
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: