Basic Information
| Provider Information | |||||||||
| NPI: | 1023030681 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STORM | ||||||||
| FirstName: | WALDEMAR | ||||||||
| MiddleName: | G | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 801 BROADWAY N | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581023641 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7012342261 | ||||||||
| FaxNumber: | 7012347194 | ||||||||
| Practice Location | |||||||||
| Address1: | 801 BROADWAY N | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581023641 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7012342261 | ||||||||
| FaxNumber: | 7012347194 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2006 | ||||||||
| LastUpdateDate: | 05/02/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 5336 | ND | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 574782100 | 05 | MN | MEDICAID | 15303 | 05 | ND | MEDICAID |