Basic Information
| Provider Information | |||||||||
| NPI: | 1790741080 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ULRICH | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | DEAN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | II | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 WILLMAR AVE SW | ||||||||
| Address2: | AFFILIATED COMMUNITY MEDICAL CENTERS | ||||||||
| City: | WILLMAR | ||||||||
| State: | MN | ||||||||
| PostalCode: | 56201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202315000 | ||||||||
| FaxNumber: | 3202315067 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 WILLMAR AVE SW | ||||||||
| Address2: | AFFILIATED COMMUNITY MEDICAL CENTERS | ||||||||
| City: | WILLMAR | ||||||||
| State: | MN | ||||||||
| PostalCode: | 56201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202315000 | ||||||||
| FaxNumber: | 3202315067 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2006 | ||||||||
| LastUpdateDate: | 06/10/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | H4760 | TX | N | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 207RG0100X | 33912 | MN | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 166460901 | 05 | TX | MEDICAID |