Provider Demographics
NPI:1023373438
Name:IVANIC, CHRISTOPHER JAMES (PT)
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:JAMES
Last Name:IVANIC
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 749303
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-9303
Mailing Address - Country:US
Mailing Address - Phone:843-681-2376
Mailing Address - Fax:843-757-3269
Practice Address - Street 1:64 BLUFFTON RD
Practice Address - Street 2:
Practice Address - City:BLUFFTON
Practice Address - State:SC
Practice Address - Zip Code:29910-7621
Practice Address - Country:US
Practice Address - Phone:843-681-2376
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-11
Last Update Date:2025-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
SC9916225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP01226971OtherMEDICARE RAILROAD
IL202845288Medicare PIN
ILF400114998Medicare PIN