Basic Information
Provider Information | |||||||||
NPI: | 1205897956 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | STORK | ||||||||
FirstName: | RICHARD | ||||||||
MiddleName: | JAMES | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1267 | ||||||||
Address2: |   | ||||||||
City: | MOUNT AIRY | ||||||||
State: | NC | ||||||||
PostalCode: | 270301267 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3367864522 | ||||||||
FaxNumber: | 3367893025 | ||||||||
Practice Location | |||||||||
Address1: | 110 DUTCHMAN CT | ||||||||
Address2: |   | ||||||||
City: | ELKIN | ||||||||
State: | NC | ||||||||
PostalCode: | 286212237 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3368355330 | ||||||||
FaxNumber: | 3368355337 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/31/2006 | ||||||||
LastUpdateDate: | 01/14/2014 | ||||||||
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 | 208VP0000X | MD0000021916 | TN | N |   | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine | 208VP0000X | 047537 | GA | N |   | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine | 208VP0000X | 2007-00624 | NC | N |   | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine | 208VP0000X | 2008006962 | MO | N |   | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine | 208VP0014X | 2008006962 | NC | Y |   | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine |
ID Information
ID | Type | State | Issuer | Description | 000834666M | 05 | GA |   | MEDICAID | 018XV | 01 | NC | BCBS OF NC | OTHER | 197955 | 01 | NC | MEDCOST | OTHER | 3893809 | 05 | TN |   | MEDICAID | 009976335 | 05 | AL |   | MEDICAID | 5906657 | 05 | NC |   | MEDICAID | 113000001 | 01 | MO | MEDICARE PTAN | OTHER |