Provider Demographics
NPI:1780098780
Name:KETCHAM, CHRISTOPHER FREDERICK (DO)
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:FREDERICK
Last Name:KETCHAM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3245 HEALTH DR STE 100
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-1380
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 NAVARRE PL STE 4440
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-1171
Practice Address - Country:US
Practice Address - Phone:574-647-5300
Practice Address - Fax:574-647-5305
Is Sole Proprietor?:No
Enumeration Date:2014-06-17
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02005317A208100000X, 208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300014121Medicaid
IN236040281OtherMEDICARE PTAN
IN300014121Medicaid
IN169380079OtherMEDICARE PTAN