Provider Demographics
NPI:1376966085
Name:FAIRHURST, RICK MICHAEL (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:RICK
Middle Name:MICHAEL
Last Name:FAIRHURST
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12735 TWINBROOK PKWY
Mailing Address - Street 2:ROOM 3E-10A
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852-1770
Mailing Address - Country:US
Mailing Address - Phone:301-402-7393
Mailing Address - Fax:301-402-2201
Practice Address - Street 1:12735 TWINBROOK PKWY
Practice Address - Street 2:ROOM 3E-10A
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20852-1770
Practice Address - Country:US
Practice Address - Phone:301-402-7393
Practice Address - Fax:301-402-2201
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-31
Last Update Date:2014-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0058080174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist