Provider Demographics
NPI:1396205357
Name:RICKS, THOMAS ALBERT IV (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:ALBERT
Last Name:RICKS
Suffix:IV
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:169 ASHLEY AVE RM 202
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29425-9125
Mailing Address - Country:US
Mailing Address - Phone:843-792-3451
Mailing Address - Fax:843-876-7111
Practice Address - Street 1:169 ASHLEY AVE RM 202
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29425-9125
Practice Address - Country:US
Practice Address - Phone:843-792-3451
Practice Address - Fax:843-876-7111
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-24
Last Update Date:2020-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
SCLL82637207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program