Provider Demographics
NPI:1659546273
Name:STORK, BRYAN ANTHONY (MD)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:ANTHONY
Last Name:STORK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 78009
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63178-8009
Mailing Address - Country:US
Mailing Address - Phone:866-898-7142
Mailing Address - Fax:616-975-9824
Practice Address - Street 1:4401 WORNALL RD
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64111-3220
Practice Address - Country:US
Practice Address - Phone:816-932-2171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-24
Last Update Date:2020-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-34479207P00000X
MO2008013251207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200574320BMedicaid
KS200574320DMedicaid
40358011OtherBCBS
KS200574320AMedicaid
KS200574320CMedicaid
KS200574320BMedicaid
KS200574320CMedicaid