Provider Demographics
NPI:1992051163
Name:ULRICH, CHARLES HENRY (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:HENRY
Last Name:ULRICH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 EAST 80TH STREET
Mailing Address - Street 2:#11D
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10075
Mailing Address - Country:US
Mailing Address - Phone:212-879-1752
Mailing Address - Fax:
Practice Address - Street 1:110-00 ROCKAWAY BLVD.
Practice Address - Street 2:THE NEW YORK RACING ASSOCIATION, INC
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11417
Practice Address - Country:US
Practice Address - Phone:718-659-2361
Practice Address - Fax:718-659-3592
Is Sole Proprietor?:No
Enumeration Date:2012-07-25
Last Update Date:2012-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY6-107758208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
B79646Medicare UPIN