Provider Demographics
NPI:1982876157
Name:PROVENZANO, CHRISTOPHER ROBERT (MD)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:ROBERT
Last Name:PROVENZANO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:45640 SCHOENHERR RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:SHELBY TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48315-6033
Mailing Address - Country:US
Mailing Address - Phone:586-247-4300
Mailing Address - Fax:586-532-6496
Practice Address - Street 1:45650 SCHOENHERR RD
Practice Address - Street 2:
Practice Address - City:SHELBY TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48315-6033
Practice Address - Country:US
Practice Address - Phone:586-286-7800
Practice Address - Fax:586-286-7804
Is Sole Proprietor?:No
Enumeration Date:2008-03-28
Last Update Date:2015-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301082092207RN0300X, 207RH0005X
CO49048207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207RH0005XAllopathic & Osteopathic PhysiciansInternal MedicineHypertension Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MICP4301082092OtherSTATE LICENSE