Provider Demographics
NPI:1073538120
Name:UGOLINI, KATIE R (MD)
Entity Type:Individual
Prefix:DR
First Name:KATIE
Middle Name:R
Last Name:UGOLINI
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 1:4070 LAKE DR SE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-8294
Mailing Address - Country:US
Mailing Address - Phone:616-464-4420
Mailing Address - Fax:616-464-4354
Practice Address - Street 1:4070 LAKE DR SE
Practice Address - Street 2:SUITE 202
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-8294
Practice Address - Country:US
Practice Address - Phone:616-464-4420
Practice Address - Fax:616-464-4354
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301087811174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4868680Medicaid