MEDICARE: CHRISTIAN MICHAEL PETROVICH OTR

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist	5201006389	MI

General Provider Information

NPI Number	:	1134339021
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHRISTIAN MICHAEL PETROVICH OTR

Provider Business Mailing Address
First Line	:	3103 MEADOWCROFT LN
Second Line	:
City	:	KALAMAZOO
State	:	MI
Zip	:	49004-3773
Country	:	US
Telephone Number	:	269-568-5683
Fax Number	:	866-303-9355

Provider Business Practice Location Address
First Line	:	4460 SWEET CHERRY LN
Second Line	:
City	:	KALAMAZOO
State	:	MI
Zip	:	49004-3725
Country	:	US
Telephone Number	:	269-377-5594
Fax Number	:	269-344-8991

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/22/2007
Last Update Date	:	06/18/2009

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