Healthcare Provider Details

I. General information

NPI: 1033809181
Provider Name (Legal Business Name): ALLY MARIE KORT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2023
Last Update Date: 05/11/2023
Certification Date: 05/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 PARK AVE
SAINT LOUIS MO
63104-3024
US

IV. Provider business mailing address

117 W WASHINGTON ST APT 2C
KIRKSVILLE MO
63501-2873
US

V. Phone/Fax

Practice location:
  • Phone: 314-833-2700
  • Fax:
Mailing address:
  • Phone: 785-562-6235
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS1000X
TaxonomyStudent Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: