Healthcare Provider Details

I. General information

NPI: 1528060266
Provider Name (Legal Business Name): MELISSA S VANSICKLE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2005
Last Update Date: 12/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8958 M 50
ONSTED MI
49265-9461
US

IV. Provider business mailing address

PO BOX 67000 DEPARTMENT 272801
DETROIT MI
48267-0002
US

V. Phone/Fax

Practice location:
  • Phone: 517-467-4424
  • Fax: 517-467-2226
Mailing address:
  • Phone: 517-467-4424
  • Fax: 517-467-2226

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number042.0014135
License Number StateVT
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD22034
License Number StateME
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberC1-0012671
License Number StateDE
# 4
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number60229
License Number StateCT
# 5
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberD85135
License Number StateMD
# 6
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number292455
License Number StateNY
# 7
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number25MA10290400
License Number StateNJ
# 8
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD463524
License Number StatePA
# 9
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01080001A
License Number StateIN
# 10
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD16129
License Number StateRI
# 11
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number274796
License Number StateMA
# 12
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301072779
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: