Basic Information
| Provider Information | |||||||||
| NPI: | 1528082328 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STORK | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 24701 EUCLID AVE | ||||||||
| Address2: | 3RD FLOOR | ||||||||
| City: | EUCLID | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441171714 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2163836616 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 11100 EUCLID AVE | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441061716 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2168447334 | ||||||||
| FaxNumber: | 2168443781 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2006 | ||||||||
| LastUpdateDate: | 08/19/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 35-0465395 | OH | Y | Allopathic & Osteopathic Physicians | Anesthesiology | 207LA0401X | 35-0465395 | OH | N | Allopathic & Osteopathic Physicians | Anesthesiology | Addiction Medicine | 207LC0200X | 35-0465395 | OH | N | Allopathic & Osteopathic Physicians | Anesthesiology | Critical Care Medicine | 207LH0002X | 35-0465395 | OH | N | Allopathic & Osteopathic Physicians | Anesthesiology | Hospice and Palliative Medicine | 207LP2900X | 35-0465395 | OH | N | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 207LP3000X | 35-0465395 | OH | N | Allopathic & Osteopathic Physicians | Anesthesiology | Pediatric Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 50032128 | 01 | OH | RAILROAD MEDICARE | OTHER | 732058 | 01 | OH | BUCKEYE MEDICAID | OTHER | 000000516064 | 01 | OH | ANTHEM | OTHER | 0519997 | 05 | OH | MEDICAID | P00605163 | 01 | OH | MEDICARE RAILROAD | OTHER | 4007964 | 01 | OH | AETNA | OTHER | 000000221112 | 01 | OH | UNISON | OTHER | 0583328 | 01 | OH | BCMH | OTHER | 364051 | 01 | OH | WELLCARE MEDCAID | OTHER |