Provider Demographics
NPI:1134339021
Name:PETROVICH, CHRISTIAN MICHAEL (OTR)
Entity type:Individual
Prefix:
First Name:CHRISTIAN
Middle Name:MICHAEL
Last Name:PETROVICH
Suffix:
Gender:M
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3103 MEADOWCROFT LN
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49004-3773
Mailing Address - Country:US
Mailing Address - Phone:269-568-5683
Mailing Address - Fax:866-303-9355
Practice Address - Street 1:4460 SWEET CHERRY LN
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49004-3725
Practice Address - Country:US
Practice Address - Phone:269-377-5594
Practice Address - Fax:269-344-8991
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2009-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201006389225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP15760001Medicare ID - Type UnspecifiedINDIVIDUAL PROVIDER NUMBE