Healthcare Provider Details

I. General information

NPI: 1811997539
Provider Name (Legal Business Name): MARY ULRICH M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 07/22/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1755 W HIBISCUS BLVD
MELBOURNE FL
32901-2616
US

IV. Provider business mailing address

1755 W HIBISCUS BLVD
MELBOURNE FL
32901-2616
US

V. Phone/Fax

Practice location:
  • Phone: 321-724-5437
  • Fax: 321-724-5570
Mailing address:
  • Phone: 321-724-5437
  • Fax: 321-724-5570

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME58015
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: