Provider Demographics
NPI:1851155717
Name:POGUE, MELODY JO
Entity Type:Individual
Prefix:
First Name:MELODY
Middle Name:JO
Last Name:POGUE
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 1:521 COBB ST
Mailing Address - Street 2:
Mailing Address - City:CADILLAC
Mailing Address - State:MI
Mailing Address - Zip Code:49601-2589
Mailing Address - Country:US
Mailing Address - Phone:231-775-5372
Mailing Address - Fax:231-775-5372
Practice Address - Street 1:521 COBB ST
Practice Address - Street 2:
Practice Address - City:CADILLAC
Practice Address - State:MI
Practice Address - Zip Code:49601-2589
Practice Address - Country:US
Practice Address - Phone:231-775-5372
Practice Address - Fax:231-775-5372
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-12
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172V00000XOther Service ProvidersCommunity Health WorkerGroup - Single Specialty