Provider Demographics
NPI:1548366800
Name:STOR, RENEE ANDREA (MD)
Entity type:Individual
Prefix:
First Name:RENEE
Middle Name:ANDREA
Last Name:STOR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:RICHARD
Other - Middle Name:ARTHUR
Other - Last Name:STOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2570 PTARMIGAN ST NW
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97304-2409
Mailing Address - Country:US
Mailing Address - Phone:503-566-2128
Mailing Address - Fax:
Practice Address - Street 1:5125 SKYLINE RD S
Practice Address - Street 2:SKYLINE MEDICAL OFFICE
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97306-5400
Practice Address - Country:US
Practice Address - Phone:503-361-5400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2008-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OROR MD11940207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine