Healthcare Provider Details

I. General information

NPI: 1629399464
Provider Name (Legal Business Name): TARA MARIE ULMER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2010
Last Update Date: 10/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1445 NORTH AVE
SPEARFISH SD
57783-1552
US

IV. Provider business mailing address

353 FAIRMONT BLVD ATTEN CHRISTIE MSS
RAPID CITY SD
57701-7350
US

V. Phone/Fax

Practice location:
  • Phone: 605-644-4170
  • Fax: 605-644-4198
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number8808
License Number StateSD

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: