=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528060266
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MELISSA S VANSICKLE MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/12/2005
-----------------------------------------------------
Last Update Date | 12/06/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8958 M 50
-----------------------------------------------------
City | ONSTED
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49265-9461
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-467-4424
-----------------------------------------------------
Fax | 517-467-2226
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 67000 DEPARTMENT 272801
-----------------------------------------------------
City | DETROIT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48267-0002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-467-4424
-----------------------------------------------------
Fax | 517-467-2226
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 042.0014135
-----------------------------------------------------
License Number State | VT
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | MD22034
-----------------------------------------------------
License Number State | ME
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | C1-0012671
-----------------------------------------------------
License Number State | DE
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 60229
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | D85135
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 292455
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #7
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 25MA10290400
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------
Taxonomy #8
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | MD463524
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #9
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 01080001A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------
Taxonomy #10
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | MD16129
-----------------------------------------------------
License Number State | RI
-----------------------------------------------------
Taxonomy #11
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 274796
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------
Taxonomy #12
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 4301072779
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------