Provider Demographics
NPI:1235240904
Name:TICE, ANN (MD)
Entity Type:Individual
Prefix:DR
First Name:ANN
Middle Name:
Last Name:TICE
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 1:4007 GOLF CREEK DR
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61822-9208
Mailing Address - Country:US
Mailing Address - Phone:217-351-1844
Mailing Address - Fax:
Practice Address - Street 1:1 E MAIN ST
Practice Address - Street 2:SUITE 103
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-3654
Practice Address - Country:US
Practice Address - Phone:217-693-4400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2008-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILC43490Medicare UPIN