Healthcare Provider Details

I. General information

NPI: 1730641903
Provider Name (Legal Business Name): ASHLEY DIANA MCMELLEN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2019
Last Update Date: 06/30/2025
Certification Date: 06/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6777 W MAPLE RD
WEST BLOOMFIELD MI
48322-3013
US

IV. Provider business mailing address

1 FORD PL # 3A
DETROIT MI
48202-3450
US

V. Phone/Fax

Practice location:
  • Phone: 248-325-1000
  • Fax:
Mailing address:
  • Phone: 313-874-4806
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberDR.0073269
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number35.143056
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number4301513770
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: