Provider Demographics
NPI:1902839764
Name:ICE, ANNE MARE
Entity type:Individual
Prefix:DR
First Name:ANNE MARE
Middle Name:
Last Name:ICE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22341 W 8 MILE RD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48219-1217
Mailing Address - Country:US
Mailing Address - Phone:313-255-2209
Mailing Address - Fax:313-255-0773
Practice Address - Street 1:23077 GREENFIELD RD STE 200
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-3750
Practice Address - Country:US
Practice Address - Phone:313-824-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010316832080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1066910Medicaid
MIB43111Medicare UPIN
MI0828710Medicare ID - Type Unspecified