Provider Demographics
NPI:1457332454
Name:STORM, BRADLEY W (MD)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:W
Last Name:STORM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20375 W 151ST ST
Mailing Address - Street 2:SUITE 370
Mailing Address - City:OLATHE
Mailing Address - State:KS
Mailing Address - Zip Code:66061
Mailing Address - Country:US
Mailing Address - Phone:913-782-0707
Mailing Address - Fax:913-782-5813
Practice Address - Street 1:20375 W 151ST ST #370
Practice Address - Street 2:PREMIER PLASTIC SURGERY
Practice Address - City:OLATHE
Practice Address - State:KS
Practice Address - Zip Code:66061
Practice Address - Country:US
Practice Address - Phone:913-782-0707
Practice Address - Fax:913-782-5813
Is Sole Proprietor?:No
Enumeration Date:2005-11-08
Last Update Date:2011-08-03
Deactivation Date:2005-11-08
Deactivation Code:
Reactivation Date:2006-11-17
Provider Licenses
StateLicense IDTaxonomies
KS04234382086S0105X, 2086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
No2086S0105XAllopathic & Osteopathic PhysiciansSurgerySurgery of the Hand
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS1308048OtherUNITED HEALTH CARE
KS16274034OtherBLUE CROSS
KS10012005AMedicaid
KS16274034OtherBLUE CROSS
KS10012005AMedicaid