Healthcare Provider Details

I. General information

NPI: 1457811309
Provider Name (Legal Business Name): CARLY ROSE ULRICH DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2019
Last Update Date: 08/03/2026
Certification Date: 08/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1220 LEE ST E STE 100
CHARLESTON WV
25301-1864
US

IV. Provider business mailing address

3200 MACCORKLE AVE SE FL 4
CHARLESTON WV
25304-1227
US

V. Phone/Fax

Practice location:
  • Phone: 304-388-1965
  • Fax:
Mailing address:
  • Phone: 304-388-5590
  • Fax: 304-388-8238

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number4878
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number06149
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: