Healthcare Provider Details

I. General information

NPI: 1831177526
Provider Name (Legal Business Name): SHARON LEE TICE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2006
Last Update Date: 12/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29255 NORTHWESTERN HWY SUITE 100
SOUTHFIELD MI
48034-1018
US

IV. Provider business mailing address

PO BOX 33321 DRAWER 117
DETROIT MI
48232-5321
US

V. Phone/Fax

Practice location:
  • Phone: 248-358-2410
  • Fax: 248-358-2470
Mailing address:
  • Phone: 248-358-2410
  • Fax: 248-358-2470

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301036723
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: