Provider Demographics
NPI:1881788149
Name:ULLRICH, GEORGE JACKSON (MD)
Entity type:Individual
Prefix:
First Name:GEORGE
Middle Name:JACKSON
Last Name:ULLRICH
Suffix:
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:PO BOX 1356
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83816
Mailing Address - Country:US
Mailing Address - Phone:208-765-0955
Mailing Address - Fax:208-765-6972
Practice Address - Street 1:1115 IRONWOOD DRIVE
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814
Practice Address - Country:US
Practice Address - Phone:208-765-0955
Practice Address - Fax:208-765-6972
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM64002084P0800X
WAMD000314162084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT22698OtherMONTANA MEDICAID
ID33852OtherBLUE CROSS OF IDAHO
000010000418OtherBLUE CROSS BLUE SHIELD
E57005Medicare UPIN