Healthcare Provider Details

I. General information

NPI: 1629161773
Provider Name (Legal Business Name): MICHAEL J ULICH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 05/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1232 SHEPPARD ST
MINDEN LA
71055-3460
US

IV. Provider business mailing address

1232 SHEPPARD ST
MINDEN LA
71055-3460
US

V. Phone/Fax

Practice location:
  • Phone: 318-377-7116
  • Fax: 318-377-9979
Mailing address:
  • Phone: 318-377-7116
  • Fax: 318-377-9979

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number201080
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License Number201080
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: