Provider Demographics
NPI:1033809181
Name:KORT, ALLY MARIE
Entity Type:Individual
Prefix:
First Name:ALLY
Middle Name:MARIE
Last Name:KORT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 W WASHINGTON ST APT 2C
Mailing Address - Street 2:
Mailing Address - City:KIRKSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63501-2873
Mailing Address - Country:US
Mailing Address - Phone:785-562-6235
Mailing Address - Fax:
Practice Address - Street 1:1500 PARK AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63104-3024
Practice Address - Country:US
Practice Address - Phone:314-833-2700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-11
Last Update Date:2023-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health