Healthcare Provider Details

I. General information

NPI: 1134339021
Provider Name (Legal Business Name): CHRISTIAN MICHAEL PETROVICH OTR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2007
Last Update Date: 06/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4460 SWEET CHERRY LN
KALAMAZOO MI
49004-3725
US

IV. Provider business mailing address

3103 MEADOWCROFT LN
KALAMAZOO MI
49004-3773
US

V. Phone/Fax

Practice location:
  • Phone: 269-377-5594
  • Fax: 269-344-8991
Mailing address:
  • Phone: 269-568-5683
  • Fax: 866-303-9355

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number5201006389
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: