NPIMap

Organization Active NPI

Baltimore Ketamine Clinic

  • Infusion Therapy Clinic/Center
  • Sparks, MD
National Provider Identifier
1508580275
Registry record updated Sep 27, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Infusion Therapy Clinic/CenterTaxonomy code 261QI0500X
Legal business name
BALTIMORE KETAMINE CLINIC
Practice address
909 Ridgebrook Rd Ste 202
Sparks, MD 21152-9476
Phone
(410) 870-5482
NPI assigned
Sep 27, 2022
Last updated
Sep 27, 2022By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Sep 27, 2022

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

Authorized official

Name
Ivana Mitic, CRNANPI 1962743815
Title
Ceo
Phone
(410) 870-5482

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Infusion Therapy Clinic/Center 261QI0500X Primary

Addresses

Primary practice location

909 Ridgebrook Rd Ste 202
Sparks, MD 21152-9476

Mailing address

909 Ridgebrook Rd Ste 202
Sparks, MD 21152-9476

Other identifiers 1

IdentifierTypeStateIssuer
209047300MedicaidMD

National Provider Directory

National Provider Directory
Tax ID family
Baltimore Ketamine Clinic2 organizations share this tax ID, including this one

Other organizations with this tax ID 1

Organizations that report the same tax identification number in the National Provider Directory.

Practitioners & affiliated clinicians

Practitioners 3

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": "1664236800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1664236800000",
    "number": "1508580275",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "909 RIDGEBROOK RD STE 202",
            "city": "SPARKS",
            "state": "MD",
            "postal_code": "211529476"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "909 RIDGEBROOK RD STE 202",
            "city": "SPARKS",
            "state": "MD",
            "postal_code": "211529476",
            "telephone_number": "410-870-5482"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "BALTIMORE KETAMINE CLINIC",
        "organizational_subpart": "NO",
        "enumeration_date": "2022-09-27",
        "last_updated": "2022-09-27",
        "certification_date": "2022-09-21",
        "status": "A",
        "authorized_official_last_name": "MITIC",
        "authorized_official_first_name": "IVANA",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "410-870-5482",
        "authorized_official_credential": "CRNA"
    },
    "taxonomies": [
        {
            "code": "261QI0500X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Infusion Therapy",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "209047300",
            "state": "MD"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Sparks, MD

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 27, 2022; 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.