Provider Demographics
NPI:1144693870
Name:ULBRICH FAMILY MEDICINE, LLC
Entity type:Organization
Organization Name:ULBRICH FAMILY MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMIE
Authorized Official - Middle Name:GRANT
Authorized Official - Last Name:ULBRICH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:660-631-3386
Mailing Address - Street 1:2301 S HIGHWAY 65
Mailing Address - Street 2:SUITE 2
Mailing Address - City:MARSHALL
Mailing Address - State:MO
Mailing Address - Zip Code:65340-3702
Mailing Address - Country:US
Mailing Address - Phone:660-631-3386
Mailing Address - Fax:
Practice Address - Street 1:2301 S HIGHWAY 65
Practice Address - Street 2:SUITE 2
Practice Address - City:MARSHALL
Practice Address - State:MO
Practice Address - Zip Code:65340-3702
Practice Address - Country:US
Practice Address - Phone:660-631-3386
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-03
Last Update Date:2015-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOMD105523207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOMA5902Medicare Oscar/Certification