Provider Demographics
NPI:1487646691
Name:ULLRICH, PETER F JR (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:F
Last Name:ULLRICH
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5320 MICHAELS DR
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54913-8446
Mailing Address - Country:US
Mailing Address - Phone:920-882-8200
Mailing Address - Fax:920-882-8210
Practice Address - Street 1:5320 MICHAELS DR
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54913-8446
Practice Address - Country:US
Practice Address - Phone:920-882-8200
Practice Address - Fax:920-882-8210
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2013-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI36628208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32123400Medicaid
WI45105Medicare ID - Type Unspecified
G04139Medicare UPIN