Provider Demographics
NPI:1548441405
Name:MARK W ULRICKSON DO PLC
Entity type:Organization
Organization Name:MARK W ULRICKSON DO PLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:W
Authorized Official - Last Name:ULRICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO PLC
Authorized Official - Phone:906-225-4512
Mailing Address - Street 1:1414 W FAIR AVE STE 347
Mailing Address - Street 2:
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855-5407
Mailing Address - Country:US
Mailing Address - Phone:906-225-4512
Mailing Address - Fax:906-225-4514
Practice Address - Street 1:1414 W FAIR AVE STE 347
Practice Address - Street 2:
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-5407
Practice Address - Country:US
Practice Address - Phone:906-225-4512
Practice Address - Fax:906-225-4514
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-20
Last Update Date:2008-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4500051Medicaid
MIV54151Medicare UPIN