Provider Demographics
NPI:1790741080
Name:ULRICH, CHARLES DEAN II (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:DEAN
Last Name:ULRICH
Suffix:II
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 1:101 WILLMAR AVE SW
Mailing Address - Street 2:AFFILIATED COMMUNITY MEDICAL CENTERS
Mailing Address - City:WILLMAR
Mailing Address - State:MN
Mailing Address - Zip Code:56201
Mailing Address - Country:US
Mailing Address - Phone:320-231-5000
Mailing Address - Fax:320-231-5067
Practice Address - Street 1:101 WILLMAR AVE SW
Practice Address - Street 2:AFFILIATED COMMUNITY MEDICAL CENTERS
Practice Address - City:WILLMAR
Practice Address - State:MN
Practice Address - Zip Code:56201
Practice Address - Country:US
Practice Address - Phone:320-231-5000
Practice Address - Fax:320-231-5067
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2008-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH4760207RG0100X
MN33912207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX166460901Medicaid
F35038Medicare UPIN
TX8C1214Medicare ID - Type Unspecified