1972145381 NPI number — BALTIMORE KETAMINE CLINIC

Table of content: (NPI 1972145381)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972145381 NPI number — BALTIMORE KETAMINE CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BALTIMORE KETAMINE CLINIC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1972145381
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/02/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1 TEXAS STATION CT STE 320
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TIMONIUM
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21093-8290
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-870-5482
Provider Business Mailing Address Fax Number:
410-628-1212

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
909 RIDGEBROOK RD STE 202
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPARKS GLENCOE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21152-9476
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-870-5482
Provider Business Practice Location Address Fax Number:
410-628-1212
Provider Enumeration Date:
10/17/2019

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MITIC
Authorized Official First Name:
IVANA
Authorized Official Middle Name:
Authorized Official Title or Position:
GROUP OWNER
Authorized Official Telephone Number:
713-412-3462

Provider Taxonomy Codes

  • Taxonomy code: 261QI0500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)