Basic Information
| Provider Information | |||||||||
| NPI: | 1386932192 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STORK | ||||||||
| FirstName: | ANGELA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 855 ILLINI DR STE 304 | ||||||||
| Address2: | |||||||||
| City: | SILVIS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 612822904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3092812120 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 855 ILLINI DR STE 304 | ||||||||
| Address2: | |||||||||
| City: | SILVIS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 612822904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3092812120 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2011 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | R72675 | AZ | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | R9668 | IA | Y | Allopathic & Osteopathic Physicians | Surgery |
No ID Information.