=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396707311
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | VICTORIA STORM SHEPHERD PA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/05/2006
-----------------------------------------------------
Last Update Date | 12/29/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4180 WARRENSVILLE CENTER RD 120
-----------------------------------------------------
City | BEACHWOOD
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44122-7024
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 440-834-1833
-----------------------------------------------------
Fax | 440-834-1902
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 391405
-----------------------------------------------------
City | SOLON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44139-8405
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-496-4433
-----------------------------------------------------
Fax | 440-834-1902
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | 50001447
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------