Provider Demographics
NPI:1548600984
Name:ROSEN, KATIE MARIE (DO)
Entity Type:Individual
Prefix:DR
First Name:KATIE
Middle Name:MARIE
Last Name:ROSEN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20952 E 12 MILE RD STE 200
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48081-3203
Mailing Address - Country:US
Mailing Address - Phone:586-771-4820
Mailing Address - Fax:586-771-6620
Practice Address - Street 1:19991 HALL RD STE 201
Practice Address - Street 2:
Practice Address - City:MACOMB
Practice Address - State:MI
Practice Address - Zip Code:48044
Practice Address - Country:US
Practice Address - Phone:586-228-0150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-30
Last Update Date:2018-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101020639208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MICB9133OtherRAILROAD MEDICARE
MI0E06273OtherBCBSM