Healthcare Provider Details

I. General information

NPI: 1104819770
Provider Name (Legal Business Name): RUDOLF ULIRSCH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2005
Last Update Date: 05/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1970 ROANOKE BLVD
SALEM VA
24153-6404
US

IV. Provider business mailing address

1970 ROANOKE BLVD
SALEM VA
24153-6404
US

V. Phone/Fax

Practice location:
  • Phone: 540-982-2463
  • Fax: 540-224-1923
Mailing address:
  • Phone: 540-982-2463
  • Fax: 540-224-1923

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number139287
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207ZC0500X
TaxonomyCytopathology Physician
License Number139287
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code207ZH0000X
TaxonomyHematology (Pathology) Physician
License Number139287
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: