MEDICARE: JEFFREY STORMER CRNA

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	163W00000X	Registered Nurse	1028649	KY
2	367500000X	Certified Registered Nurse Anesthetist	023081	KY
3	163W00000X	Registered Nurse	154045	OH
4	367500000X	Certified Registered Nurse Anesthetist	NA00804	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	000000537064	OTHER	ANTHEM
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	9130423	OTHER	PHCS
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1639154685
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEFFREY STORMER CRNA

Provider Business Mailing Address
First Line	:	1 MEDICAL VILLAGE DR
Second Line	:
City	:	EDGEWOOD
State	:	KY
Zip	:	41017-3403
Country	:	US
Telephone Number	:	859-301-2000
Fax Number	:	859-341-7867

Provider Business Practice Location Address
First Line	:	20 MEDICAL VILLAGE DR
Second Line	:	STE 258
City	:	EDGEWOOD
State	:	KY
Zip	:	41017-5401
Country	:	US
Telephone Number	:	859-341-2666
Fax Number	:	859-341-7867

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

Provider Enumeration Date	:	12/13/2005
Last Update Date	:	09/16/2016

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Directions to “ JEFFREY STORMER CRNA” Practice Location

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