Basic Information
| Provider Information | |||||||||
| NPI: | 1992721641 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ICE | ||||||||
| FirstName: | MONIQUE | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | AVERILL | ||||||||
| OtherFirstName: | MONIQUE | ||||||||
| OtherMiddleName: | R | ||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3621 S STATE ST | ||||||||
| Address2: | 700 KMS PLACE | ||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7349362047 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1500 EAST MEDICAL CENTER DR | ||||||||
| Address2: | B1 FLOOR UNIVERSITY HOSPITAL RECP EMERGENCY | ||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481095301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7349366666 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2006 | ||||||||
| LastUpdateDate: | 03/26/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 35-086356 | OH | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 4301089423 | MI | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | P00266147 | 01 | OH | RAILROAD MEDICARE | OTHER | 2594241 | 05 | OH | MEDICAID |