Provider Demographics
NPI:1629399464
Name:ULMER, TARA MARIE (MD)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:MARIE
Last Name:ULMER
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 1:353 FAIRMONT BLVD
Mailing Address - Street 2:ATTEN CHRISTIE MSS
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57701-7350
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1445 NORTH AVE
Practice Address - Street 2:
Practice Address - City:SPEARFISH
Practice Address - State:SD
Practice Address - Zip Code:57783-1552
Practice Address - Country:US
Practice Address - Phone:605-644-4170
Practice Address - Fax:605-644-4198
Is Sole Proprietor?:No
Enumeration Date:2010-06-16
Last Update Date:2013-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD8808208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics