MEDICARE: FRED C STORM MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207VG0400X	Gynecology Physician	100428	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1497709232
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	FRED C STORM MD

Provider Business Mailing Address
First Line	:	195 BULOCK RD.
Second Line	:
City	:	SLINGERLANDS
State	:	NY
Zip	:	12159
Country	:	US
Telephone Number	:	518-439-3011
Fax Number	:

Provider Business Practice Location Address
First Line	:	259 LARK ST
Second Line	:
City	:	ALBANY
State	:	NY
Zip	:	12210-1108
Country	:	US
Telephone Number	:	518-434-5678
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/19/2006
Last Update Date	:	12/13/2011

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