Healthcare Provider Details

I. General information

NPI: 1639347586
Provider Name (Legal Business Name): ANNE-MARE ICE MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2008
Last Update Date: 02/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22341 W 8 MILE RD
DETROIT MI
48219-1217
US

IV. Provider business mailing address

22341 W 8 MILE RD
DETROIT MI
48219-1217
US

V. Phone/Fax

Practice location:
  • Phone: 313-255-2209
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number4301031683
License Number StateMI

VIII. Authorized Official

Name: MRS. KASSANDRA A HILL
Title or Position: GENERAL MANAGER
Credential:
Phone: 313-255-4672