Provider Demographics
NPI:1497043970
Name:ILITCH, MELANIE ELAINE (PA)
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:ELAINE
Last Name:ILITCH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MELANIE
Other - Middle Name:ELAINE
Other - Last Name:GROVE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:36800 WOODWARD AVE STE 210
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48304-0917
Mailing Address - Country:US
Mailing Address - Phone:248-543-3566
Mailing Address - Fax:
Practice Address - Street 1:36800 WOODWARD AVE STE 210
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48304-0917
Practice Address - Country:US
Practice Address - Phone:248-543-3566
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-18
Last Update Date:2023-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601006054363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant