Provider Demographics
NPI:1316054414
Name:ICE, MELONIE SUE (MD)
Entity type:Individual
Prefix:
First Name:MELONIE
Middle Name:SUE
Last Name:ICE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 EAST PARIS AVE SE STE 100
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-3680
Mailing Address - Country:US
Mailing Address - Phone:616-459-3158
Mailing Address - Fax:616-988-0071
Practice Address - Street 1:1000 EAST PARIS AVE SE STE 100
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546
Practice Address - Country:US
Practice Address - Phone:616-459-3158
Practice Address - Fax:616-988-0071
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2022-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301406808207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1104128442OtherBCBS OF MICHIGAN
MI1989421Medicaid
MI1104128442OtherBCBS OF MICHIGAN
MI0D16122001Medicare PIN
MI0D16122001Medicare PIN