NPIMap

Organization Active NPI

Revive Ketamine Clinic, PLLC

  • Medical Specialty Clinic/Center
  • Bartlett, TN
National Provider Identifier
1053984484
Registry record updated Apr 15, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Medical Specialty Clinic/CenterTaxonomy code 261QM2500X
Legal business name
REVIVE KETAMINE CLINIC, PLLC
Practice address
5820 Stage Rd
Bartlett, TN 38134-4518
Phone
(901) 317-7900
Fax
(901) 317-7899
NPI assigned
Jul 22, 2021
Last updated
Apr 15, 2024By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 15, 2024

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Ginger Williams, DNP, CRNANPI 1154488328
Title
Owner/Practitioner
Phone
(901) 317-7900

Authorized official NPPES reports the official by name only. The link goes to the one practitioner with that name whose NPPES practice address or phone number is this organization’s.

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Medical Specialty Clinic/Center 261QM2500X NU Primary
Psychiatric/Mental Health Nurse Practitioner 363LP0808X NU

Addresses

Primary practice location

5820 Stage Rd
Bartlett, TN 38134-4518

Mailing address

5820 Stage Rd
Bartlett, TN 38134-4518
Phone (901) 317-7900

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1626912000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1713139200000",
    "number": "1053984484",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "5820 STAGE RD",
            "city": "BARTLETT",
            "state": "TN",
            "postal_code": "381344518",
            "telephone_number": "901-317-7900",
            "fax_number": "901-317-7899"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "5820 STAGE RD",
            "city": "BARTLETT",
            "state": "TN",
            "postal_code": "381344518",
            "telephone_number": "901-317-7900",
            "fax_number": "901-317-7899"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "REVIVE KETAMINE CLINIC, PLLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2021-07-22",
        "last_updated": "2024-04-15",
        "certification_date": "2024-04-15",
        "status": "A",
        "authorized_official_last_name": "WILLIAMS",
        "authorized_official_first_name": "GINGER",
        "authorized_official_title_or_position": "OWNER/PRACTITIONER",
        "authorized_official_telephone_number": "901-317-7900",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "DNP, CRNA"
    },
    "taxonomies": [
        {
            "code": "261QM2500X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Medical Specialty",
            "state": "NU",
            "license": null,
            "primary": true
        },
        {
            "code": "363LP0808X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Psychiatric/Mental Health",
            "state": "NU",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Bartlett, TN

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 15, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.