Provider Demographics
NPI:1659369726
Name:STORK, BRIAN R (MD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:R
Last Name:STORK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3621 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108-1633
Mailing Address - Country:US
Mailing Address - Phone:734-647-5299
Mailing Address - Fax:
Practice Address - Street 1:1301 MERCY DR
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49444-1837
Practice Address - Country:US
Practice Address - Phone:231-739-9492
Practice Address - Fax:231-739-8932
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2020-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301067607208800000X
MIBS067607208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4416691Medicaid
MI0F16430Medicare ID - Type Unspecified
MI4416691Medicaid