Provider Demographics
NPI:1871288217
Name:PETERSON, KATHERINE ROSE (MD)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:ROSE
Last Name:PETERSON
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:KATIE
Other - Middle Name:ROSE
Other - Last Name:PETERSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:275 MICHIGAN ST NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2531
Mailing Address - Country:US
Mailing Address - Phone:616-391-8810
Mailing Address - Fax:
Practice Address - Street 1:275 MICHIGAN ST NE FL 8
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2531
Practice Address - Country:US
Practice Address - Phone:616-391-8810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-11
Last Update Date:2025-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4351051362208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics