Provider Demographics
NPI:1376717355
Name:FINE, KATIE
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:
Last Name:FINE
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 1:1350 S KINGS DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28207-2134
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1350 S KINGS DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28207-2134
Practice Address - Country:US
Practice Address - Phone:704-446-1422
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-21
Last Update Date:2020-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9801260208000000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC276554OtherUNISON
SC20092581OtherSELECT HEALTH
SC571029311009OtherBLUECHOICE
NC1376717355Medicaid
SC571029311008OtherTRICARE STANDARD
SC571029311009OtherBCBS
NC891177UMedicaid
SC318212Medicaid
SCAA37638862Medicare PIN
SC571029311008OtherTRICARE STANDARD
SC20092581OtherSELECT HEALTH
SC276554OtherUNISON