Healthcare Provider Details

I. General information

NPI: 1568646842
Provider Name (Legal Business Name): JEFFREY MICHAEL ULIS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/22/2007
Last Update Date: 09/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 W MCKINLEY AVE
DECATUR IL
62526-3286
US

IV. Provider business mailing address

2300 N EDWARD ST GSBLL
DECATUR IL
62526-4163
US

V. Phone/Fax

Practice location:
  • Phone: 217-876-3682
  • Fax: 217-876-3345
Mailing address:
  • Phone: 217-876-2857
  • Fax: 217-876-2874

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number036.127081
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: