Healthcare Provider Details

I. General information

NPI: 1548600984
Provider Name (Legal Business Name): KATIE MARIE ROSEN DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2013
Last Update Date: 06/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19991 HALL RD STE 201
MACOMB MI
48044
US

IV. Provider business mailing address

20952 E 12 MILE RD STE 200
SAINT CLAIR SHORES MI
48081-3203
US

V. Phone/Fax

Practice location:
  • Phone: 586-228-0150
  • Fax:
Mailing address:
  • Phone: 586-771-4820
  • Fax: 586-771-6620

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number5101020639
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: