Provider Demographics
NPI:1407288384
Name:RICKS, KOURTNEY ALISSA (MD)
Entity Type:Individual
Prefix:
First Name:KOURTNEY
Middle Name:ALISSA
Last Name:RICKS
Suffix:
Gender:F
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 64442
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-4442
Mailing Address - Country:US
Mailing Address - Phone:410-328-8040
Mailing Address - Fax:443-462-3514
Practice Address - Street 1:827 LINDEN AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-4606
Practice Address - Country:US
Practice Address - Phone:410-225-8790
Practice Address - Fax:410-225-8910
Is Sole Proprietor?:No
Enumeration Date:2013-08-02
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD80044207R00000X, 208M00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program