Healthcare Provider Details

I. General information

NPI: 1619263563
Provider Name (Legal Business Name): TIMOTHY J ULRICH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2011
Last Update Date: 05/05/2021
Certification Date: 05/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2003 KOOTENAI HEALTH WAY
COEUR D ALENE ID
83814-6051
US

IV. Provider business mailing address

2003 KOOTENAI HEALTH WAY
COEUR D ALENE ID
83814-6051
US

V. Phone/Fax

Practice location:
  • Phone: 208-625-5187
  • Fax: 208-625-6892
Mailing address:
  • Phone: 208-625-5187
  • Fax: 208-625-6892

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License NumberM-13706
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: