Provider Demographics
NPI:1992721641
Name:ICE, MONIQUE R (MD)
Entity type:Individual
Prefix:
First Name:MONIQUE
Middle Name:R
Last Name:ICE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MONIQUE
Other - Middle Name:R
Other - Last Name:AVERILL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3621 S STATE ST
Mailing Address - Street 2:700 KMS PLACE
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108
Mailing Address - Country:US
Mailing Address - Phone:734-936-2047
Mailing Address - Fax:
Practice Address - Street 1:1 HURLEY PLZ # ED
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48503-5902
Practice Address - Country:US
Practice Address - Phone:810-262-9429
Practice Address - Fax:810-262-9104
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2023-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-086356207P00000X
MI4301089423207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2594241Medicaid
OHP00266147OtherRAILROAD MEDICARE
OHAV4169941Medicare ID - Type Unspecified
MII42441Medicare UPIN
OH2594241Medicaid