Provider Demographics
NPI:1760451850
Name:EVANICH, CHRISTOPHER J (MD)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:J
Last Name:EVANICH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3077 N MAYFAIR RD STE 305
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53222-4305
Mailing Address - Country:US
Mailing Address - Phone:414-384-6700
Mailing Address - Fax:414-727-1058
Practice Address - Street 1:3237 S 16TH ST
Practice Address - Street 2:SUITE 210
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215-4526
Practice Address - Country:US
Practice Address - Phone:414-384-6700
Practice Address - Fax:414-384-3008
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2020-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI32282207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32197400Medicaid
WI32197400Medicaid
012950034Medicare PIN